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

At our last inspection of the service, we found the service was not well managed. There was a system of audits and quality assurance checks taking place, but they were not effective, as they had not identified all the issues we found with care plans, risk assessments, medicines, infection control and fluid and repositioning records. At our last inspection of the service, we found the providers failure to assess, monitor and improve the quality and safety of the services provided was a breach of regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider had not conducted investigations into incidents to understand the cause, which would help prevent similar incidents from happening again. Where investigations had been carried out recommendations did not result in sustained improvements across the service. At this assessment we found that enough improvement had been made at this inspection and the provider was no longer in breach of regulation 17.

This service scored 75 (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 regularly attended provider forums run by the local authority where they learned about and shared good practice. They found the forums helpful and had used their learning to improve the service. For example, they learned about the local authority’s complex care team. Complex care team managers were currently helping the home with residents with a high falls risk. The deputy manager told us they regularly attended local authority infection control forums where they learned about latest infection prevention information and implement what they had learned into the service. The registered manager told us they worked closely with the local authority commissioning team. At a recent meeting with the local authority, the provider was advised that they had recently come out of the provider concerns process. They had received very positive feedback from the local authority. The registered manager told us they had plans in place for designating units to specialise in key areas of care, for example, dementia, mental health, and complex nursing care needs. This would ensure that each unit’s environment was conducive to providing the appropriate care and support for each resident. The registered manager told us they had plans in place for designating units to specialise in key areas of care, for example, dementia, mental health, and complex nursing care needs. This would ensure that each unit’s environment was conducive to providing the appropriate care and support for each resident.

The provider had reviewed equality and diversity within the service in June 2024. Recommendations were made for example, organising events to celebrate cultures and identities, run awareness campaigns to educate on different aspects of diversity and appointing diversity champions within the service to advocate and guide on equality matters. Despite this review, there were still shortfalls in standards of care, where some care plans did not have people's culture, relationship or sexuality information documented. The provider carried out a staff, residents, and relatives survey in 2023. The registered manager told us they had included the feedback from staff and people into the home’s continuous improvement plan. This covered communication, complaints, safeguarding, staff training, staff recruitment, residents and relatives survey, audits, the call bell system.

The home had a registered manager in post. The registered manager demonstrated good knowledge of people’s needs and the needs of the staffing team. Staff told us they good support from the registered manager. Comments included, “There has been lots of improvements since the registered manager came in. I can see a massive change on how staff work,”, and “The registered manager has made a big difference, she has given us what we need to do our job properly. Lots of training as well,”, and “I have seen improvements in management, communication, personal care for the residents and improvements in the building.”

The registered manager was knowledgeable about their responsibilities regarding the Health and Social Care Act 2014. They were aware of the types of significant events which they were required to notify CQC about and records showed the service had submitted notifications to CQC where needed. There was an organisational structure in place and staff understood their roles, responsibilities and contributions to the service. The registered manager was supported by the provider. We saw regular monthly performance meetings were held with the provider. There were robust recruitment procedures were in place. Recruitment records included completed application forms, employment references, proof of identification and evidence that a Disclosure and Barring Service (DBS) check had been carried out. We saw shortfalls in the management of medicines, with staff not appropriately adhering to guidance in relation to skin patches. This shortfall was not picked up on the providers quality audits.

The registered manager told us they took people’s views into account. They received feedback through residents and relatives’ meetings, satisfaction surveys, and suggestion boxes. They told us they used the feedback from people to make improvements at the service.

Regular residents and relatives’ meetings were held. Issues discussed at the May 2024 meeting included refurbishment at the service and the garden, planning for activities, improving menus and people’s mealtime experience, the chef had made some taster portions of some of the new foods and invited everyone to try. There was very positive feedback on these. There were regular residents and relative’s surveys. A member of staff was allocated as the home’s ‘speak up champion’. A ‘speak up champion’ support workers to speak up when they feel that they are unable to do so by other routes. They ensure that people who speak up are supported, and that the issues they raise are responded to. The registered manager was the safeguarding lead for the service, and they were knowledgeable about safeguarding, their responsibilities and their duty of candour. The registered manager completed a monthly safeguarding report which they shared with the local authority. They also attend a ‘provider concerns’ meeting monthly, and the local authorities care home forum where information and lessons learnt were shared. There were good systems in place to oversee learning from safeguarding and accidents and incidents. The registered manager kept a tracking tool on all safeguarding concerns raised, the local authority’s enquiry, the providers own investigations and any outcomes including lessons learnt. Monthly staff meetings were held in which sharing any lessons learnt with staff was discussed and actioned. Minutes of meetings were shared with the provider’s board.

Staff told us the registered manager was approachable and listened to them. One staff member commented, “I like working at this service. The registered manager is always happy to listen to staff.” Another staff member told us, “The new registered manager has made a big difference, she given us what we need to do our job properly." Staff told us they received regular supervision. A staff member said, “We have 2 types of supervision – one type to discuss if something is not done. The other supervision is formal and takes place every 3 months. I just had one last month.”

The provider had reviewed equality and diversity within the service in June 2024. Recommendations were made for example, organising events to celebrate cultures and identities, run awareness campaigns to educate on different aspects of diversity and appointing diversity champions within the home to advocate and guide on equality matters. The provider carried out a staff, residents, and relatives survey in 2023. The registered manager told us they had included the feedback from staff and people into the continuous improvement plan. This covered communication, complaints, safeguarding, staff training, staff recruitment, residents and relatives survey, audits, the call bell system.

The registered manager showed us an improvement plan for the service. The improvement plans included areas such as maintenance issues such as, people’s mealtime experience, care planning, falls management, actioning response to call bells and medicines management. The manager showed us that the maintenance issues at the last inspection of the service had been met. We saw that a broken door had been replaced and an air conditioner in a medicine room had been repaired. We spoke with a member of the maintenance team. They showed us a maintenance log confirming that repairs were dealt with in a timely manner. They also carried out regular checks on the electrical, fire alarm, gas safety, legionella, call bell system, hoists, wheelchairs, and pressure relieving mattresses. A member of staff told us, “People’s care plans are much better now that what they were before. There is more detail about the person and their needs.” Another staff member told us, “I support people with what’s in their care plan. Families are important too, it’s always good to have the person’s life story in their care plans.” We found that significant improvements had been made at the service.

The registered manager completed a monthly safeguarding report which they shared with the local authority. They also attend a ‘provider concerns’ meeting monthly, and the local authorities care home forum where information and lessons learnt were shared. We saw audits and checks were in place that covered maintenance, care planning and risk assessments, wound care, falls, infection control, moving and hoisting equipment, pressure relieving mattresses and call bells. We also saw regular monthly performance meetings were held with the provider. Areas discussed at the May 2024 meeting included the CQC inspection, refurbishment and lessons learned. We saw a monthly provider report that covered areas such as service user records, dining experience, medicines audit reviews, safeguarding, complaints, accidents and incidents, and residents and relative’s meetings. These included action plans to make further improvements at the service. The provider had a continuous improvement plan in place. This covered communication, complaints, safeguarding, staff training, staff recruitment, residents and relatives survey, activities within the service, audits, and the call bell system, however, it did not cover the shortfalls we found at the assessment in relation to medicines. We found that significant improvements had been made at the service.

People told us they had access to health care professionals when they needed them. One person told us, “The GP and chiropodist are organised for me.” Another person told us, “If I need to see a health professional, they sort it out.”

The registered manager regularly attended provider forums run by the local authority where they learned about and shared good practice. They told us they found the forums helpful and had used their learning to improve the service. For example, they learned about the local authority’s complex care team. Complex care team managers were currently helping the home with residents with a high falls risk. The deputy manager told us they regularly attended local authority infection control forums where they learned about latest infection prevention information and implement what they had learned into the home. The registered manager told us they worked closely with the local authority commissioning team. At a recent meeting with the local authority, they were advised that they had come out of the concerns about a provider process. They had received very positive feedback from the local authority.

Partner agencies were positive on how staff supported people to engage with the wider community. People were empowered to live ordinary lives and access the community on a regular basis.

An officer from the local authority told us the service had been making improvements supported by their quality assurance team. The local authority told us they would be testing a new admission process to ensure improvements were made and maintained within the service.

The registered manager regularly attended provider forums run by the local authority where they learned about and shared good practice. They told us they found the forums helpful and had used their learning to improve the service. For example, they learned about the local authority’s complex care team. Complex care team managers were currently helping the home with residents with a high falls risk. The deputy manager told us they regularly attended local authority infection control forums where they learned about latest infection prevention information and implement what they had learned into the home. The registered manager told us they worked closely with the local authority commissioning team. At a recent meeting with the local authority, they were advised that they had come out of the concerns about a provider process. They had received very positive feedback from the local authority.

At the time of the assessment, the service was working with the local authority for ways to improve service delivery. However, we found there was still improvement required in relation to post fall management and medicines auditing. The systems and processes the service had implemented have not been operational for enough time for us to be sure of consistent and sustained good practice. The provider had a continuous improvement plan in place for the service. This covered communication, complaints, safeguarding, staff training, staff recruitment, residents and relatives survey, audits, the call bell system.