• Care Home
  • Care home

Oak House

Overall: Requires improvement read more about inspection ratings

56 St. Leonards Road, Exeter, EX2 4LS (01392) 791916

Provided and run by:
Oak House (Exeter) Ltd

Important: The provider of this service changed. See old profile

Latest inspection summary

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Our current view of the service

Requires improvement

Updated 22 October 2025

Date of assessment: 5 November 2025 to 19 November 2025. The inspection was prompted, in part, due to concerns raised with us about unsafe care and treatment being provided.

Oak House is a care home registered to provide personal care for a maximum of 26 people. Some people living at the service were living with dementia. There were 22 people living at the service at the time of our assessment visit.

At our previous assessment, the service was rated as Requires Improvement. At this assessment, we found the overall rating of the service remained as Requires Improvement.

The provider had not ensured there was a fully effective governance system in place. Whilst we identified some improvements from our last assessment, we found the absence of effective governance systems and processes had not ensured all risks were identified or mitigated.

We found examples where care records had not been completed following admission, and some records were inaccurate. Some environmental issues relating to fire safety had not been identified. Areas of medicines management were not consistent and documents relating to people’s capacity to make decisions were not always completed. Whilst we found no impact to people, the absence of effective oversight by the provider and registered manager placed people at risk.

Staff understood safeguarding processes and the service management had escalated concerns where required. There were sufficient staff on duty to meet people’s needs and staff were recruited safely. Infection control processes were monitored and there were systems to record accidents and incidents; however, improvements were needed to ensure learning from events was undertaken.

Staff were positive about their employment and spoke highly of the management and provider level support they received. Staff received an induction, training, supervision and appraisal to enable them to meet people’s needs. People’s needs relating to eating and drinking were monitored, but improvements were needed in the oversight of this.

People were cared for respectfully and treated as individuals. Staff communication with people was positive and relatives generally spoke highly of the service provided. There were systems and processes to ensure the service was responsive to people’s needs. We received some less positive feedback about staff communicating in their native language when in communal areas of the service. This information was communicated to the registered manager.

There was a vision for the service. The service worked well with other healthcare professionals, and the registered manager told us there were links in place with local schools and places of worship.

The provider was previously in breach of legal regulations in relation to Need for consent, Safe care and treatment, Safeguarding service users from abuse and improper treatment and Good governance. There was also a breach relating to failing to send statutory notifications as required by law.

Whilst some improvements were found at this assessment and the provider was no longer in breach of some of these regulations, sufficient improvements had not been made in the regulations relating to Safe care and treatment and Good governance. The provider remains in breach of these regulations.

We have asked the provider for an action plan in response to the concerns found at this assessment.

People's experience of the service

Updated 22 October 2025

We spoke with 10 people who used the service and 4 people’s relatives. We observed care delivery within the service to help us understand the experiences of people who were unable to talk with us due to their dementia. We used the Short Observational Framework for Inspection (SOFI) to help us understand the experiences of those people who could not communicate with us.

We spoke with 16 members of staff. This included the provider, the registered manager, care staff and kitchen staff. We requested feedback from 8 health and social care professionals about their views of the service and received responses from 3 of them.

People and their relatives spoke mainly positively of their experience at Oak House. People were positive about how respectfully staff supported them, and our observations supported this feedback. While people expressed general satisfaction with their care and support, our assessment found elements of risk management and governance did not meet the expected standards.

The service worked collaboratively with others, such as health and social care professionals, other providers for potential emergency situations, visiting entertainers, faith organisations and students to meet people’s needs.