Oaklands 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 looked at all quality statements for well-led apart from Partnerships and communities. The service was not Well-led. Systems and processes were not effective to ensure good governance and oversight. The provider did not independently identify risk which impacted on people’s safety and welfare. The approach to learning, improvement and innovation was inconsistent across the service and did not include the measuring and analysis of outcomes and impact. Further work was required to demonstrate effective partnership working with other stakeholders. Legal requirements were not consistently met, such as the systematic failure to submit statutory notifications. Whistleblowing policies and procedures were in place for staff to speak up freely. Leaders were aware of supporting equality, diversity and inclusion in the workforce. The provider was committed to driving improvement at the location and put an action plan in place. During our assessment of this key question, we found concerns about the oversight and management of the service which resulted in a breach of the Regulation Good governance. You can find more details of our concerns in the evidence category findings below.

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.

Not all staff, at all levels, had an understanding of equality, diversity and human rights and the strategic direction was unclear. Only 3 of the staff 14 care staff had completed equality and diversity training.

The provider failed to ensure effective systems were in place to promote a positive culture, transparency, learning and improvement. The provider failed to have systems and processes to ensure people and their representatives were engaged, included, and involved in the arrangements of their care and treatment and to the improvements of the service as whole. The manager failed to have processes to ensure that staff supervisions, team meetings and residents meetings were meaningful and effective.

At the time of the assessment the manager was not registered with CQC. The manager was new in post and lacked the knowledge and skills to ensure people received safe care and treatment. The provider told us the leadership team comprising of the manager, regional manager and themselves as the nominated individual worked together to resolve concerns. However, roles and responsibilities were not clearly defined as a clear plan of tasks and improvements were not always identified. The leadership team failed to take action in a timely way when concerns were found. The senior care staff overseeing the care workers and the shifts were open, knowledgeable, and experienced. Staff felt able to go to them for support and advice.

The manager and provider failed to address concerns and ensure that people and their representatives were involved in the service in a meaningful way. One person told us how they raised concerns to the manager and they had not felt listened to. Improvements were required to demonstrate consistently capable leadership that lead by example, and ensured risks and oversight of the service were well managed. There were significant shortfalls relating to incident investigations, and risk mitigation which were not addressed by the management team. The provider failed to have systems and audits in place to identify the concerns we found during our assessment.

Although staff reported they were able to speak out about their views of the service, there was limited evidence to support this in supervision or team meetings. Not all staff had been given a supervision. Minutes of a staff meeting held in January 2024 showed a discussion with the staff team regarding changes to their contracts. There was evidence that staff were not happy with the proposed changes. The manager’s response was “If staff do not agree they will have to tender their notice.” This response was not supportive and would not provide staff with assurance they would be valued if they spoke up and would be listened to.

The manager was unaware of the provider complaints policy and told us there were no systems in place to record people’s complaints, incidents or accidents. This meant the provider failed to analyse or have robust oversight of themes and trends in complaints and concerns. The manager could not demonstrate how they would prevent similar issues from happening again. One person told us of a complaint they had made. We checked with the manager it was confirmed this had not been recorded or acted on under a formal complaints process. The process for induction and supervision of staff was in place, however not all staff had received supervision with the manager. The recording of supervisions were poor and did not show two way discussions about work related matters.

The manager showed a lack of knowledge and understanding of workforce equality, diversity and inclusion. When asked about reasonable adjustments made for staff, the manager gave us an example of how they would deal with pregnancy and maternity in the workplace. Their response did not consider that pregnancy was a minority group protected by the Equality Act and could be seen as discriminatory. However, the manager also told us staff should be treated equally and have equal rights.

The manager and provider failed to have systems in place to seek staff feedback in areas such as the setting up of the rota, to promote fairness amongst the staff team. The provider and manager failed to ensure all staff have received equality and diversity training to broaden staffs wider understanding of equality and diversity. The provider had a policy for equality, diversity, and inclusion however the policy did not detail what the 9 protected characteristics are.

The manager told us that they completed checks on the quality of the service, but these were not formalized or recorded. The manager told us they had oversight of the service, however they failed to identify the significant and widespread concerns highlighted within this assessment. The manager was unable to tell us any lessons learnt, or improvements implemented as a result of any incidents that occurred. The provider and manager failed to report notifiable incidents to CQC as required by law because the manager was unaware of the requirements. The manager told us that they had failed to complete a pre-assessment of one person which had resulted in an unsuitable admission to the service, putting the person and others using the service at risk. Feedback from staff and the leadership team did not provide assurance or evidence of robust and effective, governance and oversight systems.

The provider failed to have effective systems to ensure compliance with legislation. The providers internal governance were poor. There was a lack of oversight of the service as the provider and manager did not complete any formal checks on the service to identify where improvements were needed. For example, fire safety and hygiene requirements. Governance processes were not established and monitored to ensure safe and good quality care, in areas including assessments, care planning, safeguarding, health and safety and audits. Where audits were in place, they were insufficiently detailed, and care plans were not updated in a timely way. Legal and regulatory requirements were not consistently met, such as failure to submit statutory notifications. These are notifications the provider must make to the CQC for certain issues such as safeguarding concerns or serious injuries.

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.

The manager did not demonstrate a focus on continuous learning, innovation, and improvement across the service. The provider failed to have systems in place to encourage creative ways of delivering equality of experience, outcome and quality of life for people. The provider was in the process of improving the living environment for people, which they told us, in retrospect, they should have focussed on people’s care and safety. Staff training in areas where knowledge was lacking, was not always delivered in priority order, for example staff were supporting people who were at risk of choking. Only 5 of the 14 care staff employed, had completed dysphagia training, aimed at reducing people’s risk of choking.

There were significant and widespread concerns identified during this assessment. The leadership team could not evidence that action had been taken to learn and improve the quality of the service. The provider failed to implement a consistent approach to measure outcomes, utilise best practice guidance and monitor the impact and quality of care for people. The lack of systems to monitor effective practice in areas such as medicines management; risks and mitigation and health and safety requirements put people at risk of harm. For example, 2 people with limited capacity had been able to leave the service without the knowledge of staff, which put them at risk of harm.