The Oaks Care Home

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• 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 a breach in relation to governance. The provider failed to demonstrate systems for governance and oversight in place were effective at assessing, monitoring and driving improvement in the quality and safety of the services provided. This included; monitoring and responding to the quality of the experience for service users, assessing, monitoring and mitigation of risks relating to the health, safety, and welfare of service users and others, and maintaining accurate, and complete detailed records in respect of each person using the service.

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff were not confident in the leadership at the service and told us of concerns they had raised where no action had been taken. There had been no continuity of leadership at the service for a long time and this impacted the care people were receiving and the morale of staff.

The organisation had failed to identify problems at the service in a timely manner. Prior to this assessment they had began to recognise that shortfalls were significant. The provider did not have effective systems that assessed or monitored the day-to-day culture of the service. This meant there was areas of the service where significant improvements were needed to reduce the risk of a closed culture. Concerns were found in safeguarding, the environment involving people to manage risk, staffing, dignity and privacy and governance. The leadership team were not encouraging a shared direction or culture as staff were not always being supported to have supervisions to discuss their practice or to contribute to understanding why things were going wrong. The organisation responded proactively to all the concerns that had been raised by CQC and other agencies and had started to assemble a new leadership team at the service. This work had just begun so the effectiveness of this action was not evident during this assessment.

Staff told us they felt they were able to speak up, however they were not assured action was taken when they did speak up. When we asked senior staff why concerns raised by people and relatives had not been captured or followed up, they were unaware of where these concerns had been recorded.

Whilst some systems were in place for staff to speak up, we did not always see evidence the concerns they raised had been followed up or addressed. Concerns raised by people and relatives were not captured or recorded effectively.

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.

Staff told us that the numerous changes in leadership impacted on their morale. The leadership team did not have a clear understanding of their roles and responsibilities about incidents and safeguarding reporting or responding to concerns raised by people and relatives.

The provider failed to ensure there were robust audit and governance arrangements in place to proactively, effectively monitor and identify short falls in the service. This includes identifying where improvements to quality and safety could be made to minimise risks for service users, staff and others. Improvements were needed to the quality and experience for people using the service. There was minimal evidence of learning from incidents, reflective practice or service improvement, as a result people continued to be at potential risk of harm.

People and relatives were positive about staff working with other professionals involved in their care. A relative told us, “The nurse always discusses changes to [family members] medicines with me, the SALT are involved, we had a review from the epilepsy nurse recently and I know the medicine doses.” However, people told us of incidents where further referrals should have been made to relevant agencies which did not demonstrate an open and transparent culture. People's care and treatment was not always managed effectively or concerns escalated in a timely way.

There was little evidence of leaders engaging with people, communities and partners to share learning with each other and improve practice.

Concerns had been identified by visiting professionals who had escalated these to the local authority. The local authority were currently working with the service in relation to all concerns raised.

Monitoring processes in place to reduce risks to people were not being reviewed effectively. This meant there was a risk of deterioration in people’s physical health which may not be identified in a timely way delaying appropriate referrals to other healthcare professionals. Whilst the service had a weekly visit from the GP, they were reliant on staff to provide accurate information.

The turnover of leadership at the service meant the approach to ensure improvements happen had been ineffective. Staff told us they had minimal opportunities to discuss their progress or discuss their work. One staff member told us, “I have asked continuously to do an additional qualification, I keep getting told it is in the pipeline, I want to develop my skills.”

There was no evidence of embedding learning and making improvements. Following the assessment the provider recognised the need for improvement and told us they had begun this process. A service improvement plan was in place and the senior leadership team would be monitoring this.