Oak Springs 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 assessed one quality statement in the well led key question and found both areas of good practice and areas where improvement was required. The scores for these areas have been combined with scores based on the rating from the last inspection, which was requires improvement. Our rating for this key question remains requires improvement. The provider demonstrated well established governance systems. These systems and processes ensured the delivery of good quality, sustainable care, treatment and support. Whilst we were assured that governance systems were clear and generally effective, further action was required to help address the shortfalls found in the records related to the care provided. We found no evidence of harm and the registered manager demonstrated action was already underway to improve this area.

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.

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.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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 felt the home was well led. They told us they liked the registered manager and felt they were a capable and compassionate leader. A staff member told us, "I have never had a boss like [registered manager], they are amazing, they are good listeners, very supportive."

The provider demonstrated well established responsibilities, roles, systems of accountability and good governance. These systems and processes ensured the delivery of good quality, sustainable care, treatment and support. An overarching approach to governance helped ensure the provider acted on the best information about risk, performance and outcomes. This information was used to help drive improvement within the service. Whilst we were assured that governance systems were clear and generally effective, further action was required to help address the shortfalls found in the recording of daily care notes. For example, staff had not always recorded every positional change for a person who required this to manage their skin integrity risks. For another person who was on a modified diet and was to be offered regular snacks, staff had not always recorded when this has been offered. The audits we viewed had not always effectively highlighted these shortfalls. We discussed our findings with the management team who confirmed they had already identified this and were communicating with staff via regular meetings and training.

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

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.