The Oaks

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

We identified one breach of legal regulation in relation to governance. Quality assurance systems were not always robust or consistently used to drive improvement at the home. Aspects of record keeping required improvement. This included information recorded in care plans and documentation in relation to people’s mental capacity. However, staff spoke positively about the management team; they felt supported and said there was a positive culture at the home. The service worked in partnership with other organisations to support people and there were systems in place to support workforce equality, diversity and inclusion.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager gathered regular feedback from staff, stakeholders and people who used the service. However, this had not always been effective in addressing some of the issues raised during this assessment. The provider and registered manager were transparent with us during the assessment and took our feedback in a positive manner. Staff we spoke with understood the values and vision of the service. On the whole, staff felt positive about the service and shared the same ethos in providing compassionate and quality care. One staff member told us, "I love the place, staff are positive in their work and we all work together to ensure people are happy."

People and their relatives were not always consulted before decisions were made about the service, which had impacted them. The provider evaluated the service identifying areas for improvement and was aware of some of the improvements that were required at the service.

The processes implemented by the provider were not always considered in a person-centred way. However, the provider was passionate about improving the service and had identified a lot of the concerns found at this assessment. Staff spoke positively about the registered manager. They said they were extremely supportive and provided support on a personal and professional basis. Staff told us the registered manager was approachable and always available to speak with openly with any concerns they may have. The registered manager and provider were transparent with us and informed us of complaints received regarding management changes and the oversight of the home.

The systems in place had not always been effective in ensuring identified actions were addressed promptly. For example, the provider's action plan identified actions required to improve the service and some of these actions remained outstanding 3 months later. A provider wide audit was completed for MCA's, but there wasn't a clear plan of how this would be addressed at this service. The provider worked collaboratively with and consulted external agencies to support them to identify shortfalls.

Staff told us they were confident to speak with the registered manager about any concerns they had. A staff member commented, “They are approachable and I feel they really listen." Staff were asked for their views of the service during meetings. However, there was no process in operation to collate this information and use it to drive improvements at the service.

There was a whistle blowing policy in place. Staff could access the policy if needed. Staff were also provided with the employee handbook when starting with the provider. The provider had procedures in place for staff to follow when needing to speak up.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The registered manager was aware of the improvements need and told us, "Communication with people is noted as an area of improvement and I will continue to work through the service improvement plan. It is a relatively new role for me and I am learning every day." The registered manager had worked at the service for 16 years and was fairly new to the manager role. They felt supported by staff and the provider and had identified that they required training in specific areas.

The provider's governance processes were not always robust and they did not effectively monitor the safety and quality of the service or promote good outcomes for people using the service. We identified concerns with the provider's oversight of risks to people’s health and wellbeing. There was a lack of oversight of care planning and risk assessment documentation. We identified a number of concerns with the management of MCA records. Audits completed did not thoroughly check areas such as care plans and MCA. Best interest meetings were not always available for people and the registered manager told us they had used records from a previous care service. This meant decisions were being made for people who lacked mental capacity without the proper legal authority to do so. Care plans were not easy to follow and did not always contain information regarding people's health needs. The failure to implement effective systems and processes to ensure oversight of the service was a breach of regulations.

People and their relatives expressed concerns regarding a lack of consultation and communication from the provider where changes were implemented. Recent changes made by the provider meant people were not always able to access all areas of the service without support. The service had various areas which included a coffee shop and restaurant, a small convenience shop and a library. People and relatives told us they were supported to receive care from professionals and their support was reviewed when their needs changed.

Some improvements were needed to ensure the documentation guided staff about what support people needed and that this information was accurately shared. Staff told us they worked well with visiting health care professionals to meet people’s needs and keep them safe and well.

A visiting health care professional told us they felt communication could be improved at the service noting they often had to repeat information already given to staff.

Facilities were available to encourage community local support groups used areas of the service to hold support meetings. This included Parkinson group and stroke groups. People who used the service were invited to join these groups if they wished to do so. People had regular access to health professionals and systems were in place to ensure these were requested in a timely manner.

Staff confirmed they were aware of where to go if they needed more support. The registered manager and provider shared lessons learnt with the whole staff team.

Analysis of events took place to identify lessons learned it was clear from reports how the lessons learned were cascaded to staff and how improvements in practice were implemented, monitored, and reviewed.