Oak House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment, we rated this key question Requires Improvement. At this assessment, the rating has changed to Good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 68 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Information was communicated and shared with staff through daily handovers, supervisions and regular staff meetings. Meetings gave opportunities for all to comment and provide meaningful input.

Staff commented positively on being involved and having a voice. One member of staff told us, “Handovers are in place between shifts. There is a manager and seniors at all handovers. The seniors then tell the carers on shift of any changes or need to know information.”Another staff member said, “I’m glad to say that our management board was wonderful, efficient and supportive. It’s great to say the residents and staff feel like a close‑knit family.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

All staff and relatives we spoke with were generally positive about the management team, however 1 person and a relative were unaware of who the registered manager was. The registered manager was visible and available for people, their relatives and staff. The registered manager was clear they aimed to provide good care and have good outcomes for people.

One person told us, “I know the manager. She’s lovely. She did some shopping for me. I liked her when she came to do an assessment in hospital before admission.” A relative said, “The manager was helpful during admission. She’s kept me updated on how he is settling in. She’s quite approachable.”

The provider fostered a positive culture where people knew they could speak up and their voice would be heard.

People, their relatives and staff all felt confident and comfortable speaking with the management team. For example, one staff member told us, “The manager is approachable, we can go to her with concerns. Things have changed drastically for the better since she has become the manager. Before this I had very bad concerns and feared for my job.”

There were systems and processes in place to support staff. The provider ensured staff had the opportunity to be heard at staff meetings and handovers. There was a system in place for supervision and appraisal. A staff member said, “Supervisions, appraisals, and team meetings take place regularly. These help us stay informed and offer opportunities to discuss any issues or updates.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

All staff we spoke with were positive about working at Oak House and felt they were treated with respect. There were staff meetings held, and the registered manager told us they encouraged staff to share ideas to develop the service.

The registered manager and provider were dedicated to supporting all members of their team. The home had an open and transparent, positive culture and the workforce was diverse. Staff all received the same opportunities to train and develop themselves. Staff were encouraged to contribute to service development through regular staff meetings and events.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

At our previous assessment, the provider breached the regulations relating to good governance and the sending of statutory notifications. The provider now had systems and processes in place to ensure statutory notifications were sent and was no longer in breach of this regulation. However, there were insufficient improvements relating to governance and the provider remained in breach of that regulation.

A series of audits were taking place following intervention and support from the local authority. However, these audits had not been adapted to be specific to Oak House. We found concerns in relation to the lack of oversight of care planning, which had led to a care plan not being completed. Inaccurate risk assessments had not been identified. There was no oversight of Deprivation of Liberty Safeguard applications, and best interest records were inconsistent. Some areas of medicines management required more detailed oversight, and end of life care records were not consistently completed to the same standard, which had not been identified. There was no audit in place around activities, which may have identified people were not fully happy with the current provision.

Whilst we did not identify any impact on people, the absence of a fully effective governance system placed people at risk of unsafe or poor care. The provider had a service improvement plan in place which indicated the concerns we identified were being addressed, but this was not accurate.

There was a clear management structure, with all staff being clear on their duties and responsibilities. The registered manager described a positive and supportive working relationship with the provider and senior management.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The service worked with local GP surgeries and other multi-disciplinary services where required. Healthcare professionals who responded to our feedback request told us they had good working relationships with the service. Records showed appropriate referrals were made to local authorities to support where needed. One healthcare professional told us, “I have found the management team helpful in terms of arranging visits.”

Links within the community were continuing to grow. A local school attended the service with pupils for Halloween and spent time with people. The registered manager told us some of the local churches offered communion at Oak House.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

We saw the registered manager had oversight of accidents and incidents in the service, however from records we reviewed, it was not evident this was used as a learning event to reduce risk. There was no system to ensure learning from people’s experiences of activity provision was captured, which could have improved outcomes for people.

The culture of learning, best practice, and innovation had improved since the previous assessment; however, further work was required, and time was needed to embed this into practice. The registered manager was aware of this and was encouraging the team to develop their knowledge, skills, experience and confidence with supporting people’s bespoke needs.