Oaktree Hall & Lodge

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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

Staff and management were aware of their roles and responsibilities and the service had a clear staffing structure. The new manager had worked to improve the culture at the home. There was a quality assurance system in place and the provider had good oversight of incidents affecting the service. However, we found auditing processes could be used more effectively to drive improvement.

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 new manager had been working to improve the culture of the service and had noted an improvement in the culture. The manager told us they had an open door policy. Deputy managers were based out on the floors so staff had support and there was a visible management presence. The manager understood their responsibilities to be open and honest. Feedback received so far from a recently conducted staff satisfaction survey was mainly positive. The management team told us they would be reviewing all the responses and producing a ‘you said we did’ summary in due course, to show the action taken as a result of the survey.

The provider had systems in place to ensure the service was open, honest and transparent. This included a system where senior management could monitor and review anything in the service such as accident and incidents, concerns and safeguarding issues. The provider had a set of vision and values in place, and they were in the process of gathering feedback from staff and relatives through the use of satisfaction surveys. There were processes in place to support staff to speak up if they had any concerns.

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 demonstrated they were aware of their roles and responsibilities and the service had a clear management and staffing structure. It was evident there was oversight of the service from senior staff, management and senior management. Management were visible in the service and senior management visited on a regular basis.

Governance systems were in place to monitor the service. The provider had a system to oversee the service. This included a risk register monitoring tool and regular visits to the service. Auditing systems were in place to identify areas for improvement. However, action plans were not always developed from these audits to ensure identified issues were consistently addressed. For example, one audit identified a kitchen floor required replacing but there was no action plan to address this. A full 'provider visit' had been carried out by a registered manager from a different service. This had identified multiple areas for improvement but no action plan had been developed. We also identified bed bumpers on one person’s bed that were significantly torn and were dirty. We raised this and they were changed during the inspection. It was unclear why this had not identified by the staff and addressed sooner. Systems were in place for engagement with staff, such as staff meetings. We noted an example where the management took action in response to concerns raised in one staff meeting, but records of the action taken could have been better, and their response more robust. The frequency of resident and relative meetings had also been impacted by the recent lift issue at the service, and alternative options had not been explored. The management team confirmed they had plans to resume the meetings. The manager of the service was not registered with CQC at the time of our site visit, but an application was submitted. They were registered shortly after. One relative told us, “I know the manager. She introduced herself. Is accessible. Leaves her door open and listens.”

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.