The Oaks Residential Care Home

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

The rating for the key question of Well Led has improved too Good. The recruitment of an operations manager, area manager, deputy manager and an administrator to support the registered manager had created a clear management structure, previously lacking. Systems to assess and monitor the quality and safety of the service had improved. New checks and audits had been introduced to ensure safety and compliance. However, these needed further development to ensure they identified and managed risks. The service was moving in the right direction. The provider and management team understood what was needed to ensure the improvements made were sustained and built on. Policies had improved and now reflected procedures which related directly to the service, in line with current legislation. Staff were aware of the shared vison and values of the service. These had been used as benchmark to improve the quality of the service people received, and increased staff morale. Staff were aware of the providers whistle blowing policy, the process to follow to raise concerns and were confident their voices would be heard. The registered manager was visible and led by example; they were supportive and had built a good strong staff team. The registered manager worked well with other professionals and had developed a good relationship with local authority quality improvement team. The provider employed a multi-cultural and diverse workforce. Robust measures were in place to ensure staff were treated fairly.

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.

Staff were aware of the shared vison and values of the service and told us using these as a benchmark had improved the quality of the service people received, and increased staff morale. Comments included, “All the staff have adapted so much; they have changed and have respect for everyone. The area manager has seen what needs changing, everyone is noticing the difference, resulting in 100% better outcomes for residents. It’s a nicer place for people to live, décor is good, and the activities are better funded. Staff morale has improved 100%,” and “Everyone knows they are valued. Managers know how we all work as a team, and as a team we are stronger. We are here for the residents. We want to make them feel happy.”

The previous inspection found; staff were not aware of the underpinning values of the service to ensure the delivery of good high-quality care was embedded into practice. The company values were reviewed in February 2024 based on the aims and objectives of the service. These had been translated into a set of values for staff to adhere to using the acronym THRIVE, which included trust, holistic care, respect, inclusion, value, and empowerment. Six of the 7 staff spoken with, across all areas of the service were aware of and understood the shared vision and values of the service. A residents discussion group had been implemented to obtain their thoughts and feedback on how to improve the service. The registered manager had used the CQC Resident ‘I statements’ taken from the new single assessment framework (SAF) as a questionnaire, which was completed as part of a group discussion. People shared positive feedback about staff and the food and offered thoughts and suggestions to improve the service.

Staff told us the registered manager was visible and led by example; they were supportive and had built a good strong staff team. One staff member commented, “We are having monthly meetings now; we have open discussions about the things that need to be improved. Everyone is doing great and contributing well and doing their best.” Staff were complimentary about the new management team, and the changes made. Comments included, “An area manager has been brought in; they are approachable. They listen to us and will sort things out. If they can’t deal with something, they investigate who can. They seem good” and “The new operations director can see what needs changing, everyone is noticing the difference.”

Since our last inspection the provider had employed an operations director, area manager, administrative support, and a deputy manager. The registered manager now had the right level of support to manage the service, improve delivery of the organisational vision and manage risks. Whilst the responsibility for managing the service rested with the registered manager, having the additional support from other senior managers had improved the quality of the service. There had been a co-ordinated approach from the management team to develop and implement new systems to carry out more robust audits leading to better oversight and identifying where improvements were required. However, these needed further development to ensure they consistently identified and managed risk, drove improvement, and ensure these were sustained.

Staff were aware of the providers whistle blowing policy, and the process to follow to raise concerns. They confirmed they were encouraged to raise concerns and were confident their voices would be heard. One member of staff told us, “I can go to the manager if I have got a problem, I’m good with that. Me personally I speak up, if my concern wasn’t resolved, I would go to the provider or senior managers. I’d feel comfortable speaking to the manager if I felt something was wrong.”

Our previous inspection found improvements were needed to ensure there was an open and fair culture in the service. A ‘culture is key’ session was conducted in May 2023, encouraging staff to speak up about the culture organisationally and as a team. The outcome of the meeting had been shared with the provider and registered manager and used to develop the company’s vision and values. The providers whistle blowing policy set out the values, principles and procedures underpinning their approach to whistleblowing. This contained the contact details to the relevant organisations, and helplines for staff to raise concerns in confidence. All staff had received training about whistleblowing as part of the induction and were confident they could raise concerns.

The registered manager told us, they had included people using the service in interview panels when recruiting new care staff. This ensured they had a say on who would be employed and involved in the provision of their care. Systems were in place to engage with all staff, including those less likely to speak up, via regular supervision. One member of staff commented, “I have supervision every month. I give my comments, and suggestions on how to improve things for residents and the home.”

The provider had identified and taken action to address equal opportunities for staff and improve where there were any disparities in the experience of staff with protected characteristics. The provider employed a multi-cultural and diverse workforce and had robust measures in place to ensure they were treated fairly in line with their equality, diversity, and inclusion policy. They had made reasonable adjustments to support staff with protected equality characteristics to carry out their roles well. This included the provision of information, guidance, and training to staff in various ways to meet their communication and language needs, and to support staff with disabilities, such as dyslexia.

Staff told us, the management of the service had improved with the addition of the operations director, area manager and a deputy to support the registered manager. Comments included, “We have different staff now. Staff now are all about teamwork, everyone works together. Morale is way better now than before, if something is difficult, we (managers and staff) sit down and discuss and decide how we can get it done. This didn’t happen before,” and “Big improvement. Starting with cleanliness, everything is tidy and organised. Everyone is approachable, we are meeting all their (residents) different needs. There are new staff. Everyone is contributing well, it’s a nice place to work.”

Systems to assess and monitor the quality and safety of the service had improved. New systems, checks and audits had been introduced to ensure safety and compliance. These had been rated, according to risk, using the traffic light system red, amber, and green (RAG) and were now feeding into a service improvement plan, completing the monitoring cycle. The service had a history of improvement and deterioration due to a lack of resources, investment, and oversight. At this inspection, we found the service was moving in the right direction, however the provider and management team needed to ensure the improvements made were sustained and built on to ensure they effectively monitor the service and deliver high quality care. The provider’s policies had improved and now reflected procedures which related directly to the service, in line with current legislation. Improved systems, including supervision and appraisal were in place to monitor staff actions, behaviours, and performance, and ensure they understood their roles and responsibilities.

Relatives told us communication with them and between staff had improved. One relative told us, “Communication is so good we constantly get pictures on Facebook. The home has improved so much over the past couple of years. We have a regular newsletter and meetings with residents and family members as well if they want to. Lots of opportunity to ask any questions you may have and get up to date with information.”

The registered manager told us new systems had been developed to engage with people, their relatives, visitors, and health professionals to obtain feedback about the service and share learning. A residents meeting had highlighted communication could be improved. As a result, the registered manager had introduced a monthly newsletter which had been well received by people’s relatives. Additionally, a feedback book and suggestion box had been positioned in the entrance to allow visitors to leave feedback or suggestions they felt would improve the service. They had also implemented a “You said, We did”, with easy read captions. These were displayed on the resident’s noticeboard to provide feedback to the residents and their families about the action taken to address issues raised. For example, people and their relatives had requested naming corridors to help people locate their rooms. Pictures had been used to identify the corridors, until name plates were purchased.

The local authority quality improvement team (QIT) visited this service in February 2023 and again in December 2023 to check if improvements had been made. We saw an email sent to the registered manager from a member of the QIT congratulating them on the exemplary work they had done to improve the service in a relatively short space of time. This included comments on how they had worked above and beyond to implement the tools, resources, and mechanisms to continue to develop and improve the service.

The registered manager had developed a strong external relationship with local authority quality improvement team. Following our last inspection and audit of the service by QIT team the registered manager produced an action plan demonstrating how they were making the required improvements. The QIT revisited in December 2023 and shared an email with us praising the registered manager for their hard work, good collaborative working and their commitment to people’s safety and wellbeing.

The registered manager told us all staff were encouraged to speak up with ideas for improvement and given the opportunity to have their say within the service. Staff confirmed they were encouraged to attend regular staff meetings to discuss what was working well and what improvements could be made to enhance the quality of care delivered to people using the service.

Ten staff had attended a group meeting completing a ‘well led’ questionnaire in February 2024. The meeting was based on the CQC ‘we statements’ taken from the SAF. The questionnaire was aimed at encouraging staff to share positive examples of care, things they could do better and suggestions for improvements. Analysis of the feedback demonstrated staff lacked understanding about equality and diversity and not all staff being committed to the shared vision and values. The registered manager told us they had taken action to arrange additional staff training in equality and diversity, and discussed the vision, values, and expectations of staff at a staff meeting. A new management team had been appointed. All had a good understanding of what needed to happen to build on the improvements made, ensure those improvements were sustained and to grow the service moving forward. The new operations director had devised an enhancement plan which commenced January 2024 focusing on continuous learning, innovation and improvement across the organisation and local systems. This included digital technology, best practice, developments in care sector, staff learning and development and external insight and audits. They told us this would be kept under review and developed as part of ongoing quality monitoring cycle.