Oakhurst Lodge

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 governance of the service had improved. A new management team were in place and had made improvements in the service. The provider had a range of quality assurance processes in place, and these were used effectively. This included audits of medicines, care plans and people’s environments. Staff told us they were better supported since the new managers had started. They told us, they were confident the leadership team were committed to delivering a good quality service and promoted a supportive and open culture. Staff told us they had confidence in the skills and knowledge of their leadership team. The provider had systems in place to develop the knowledge and skills of its current and future leaders and the manager’s told us they were supported by the provider in all aspects.

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 we spoke to, were able to tell us what the vision and values of the service were, the staff told us, the person is always at the centre of everything. 1 staff member told us, “The care encompasses safety for the residents and empowering them, encouraging their independence as much as we can, support and engage the residents. We do it with respect and treat all as individuals.” Staff told us they are able to approach the leadership team and they receive feedback on incidents. Staff told us they empower people to express their views by treating people equally with no discrimination. Staff confirmed they are confident their colleagues and the organisation promote high quality compassionate care. All staff members spoken to, told us they have no concerns about inequality or discrimination as a care worker. 1 staff member told us, “In supervision there is a topic of equality and discrimination, there is a mixed culture of staff from different races and countries in the home and they have room to discuss about them. They have reps from multicultural networks on Cygnet where they could express any concerns or have support.” When asked, how did you involve people, staff, and partners in the development of the services vision and values, the registered manager told us, “We discuss this in team meetings. We print off the service development plan for all staff to read. We have staff survey’s where they can share ideas. I complete a monthly update to the families where we share and planned changes to the environment or any special outings. We also have families and service user surveys and feedback forms. We sent out a questionnaire to the relatives to ask what they wanted on the keyworker feedback form. The registered manager gave us an example of what systems they have in place to seek and act upon feedback from people. They told us, “The garden project was brought up in a house meeting.

We reviewed team meetings, supervisions, and appraisal’s where the organisations values were reviewed, discussed, and monitored to ensure they were embedded into practise. We reviewed evidence in the organisation’s recruitment processes of inclusion. When we reviewed people’s daily notes, we could see evidence of the organisation’s values being upheld. When asked what systems they have in place to prevent the development of a closed culture within the service. The registered manager told us, “We have a yearly cultural visit from the regional quality managers, they come and do a culture audit where they come round and speak to the staff that are on site and get their feedback on how they are feeling. We also have our freedom to speak up lead who will talk to the staff and see how they are feeling and if they need anything. The registered manager told us, they share learning with staff through team meetings where they discuss lessons learned, safeguarding, complaints, and compliments.” The registered manager was passionate about ensuring the people they are supporting live the best possible lives which is in line with the organisation’s values. Therefore, we were assured the organisation fostered a shared direction and culture among their employees.

We spoke with staff members who had an understanding of the vision and values of the service. When asked, do you have confidence in the skills and knowledge of the leadership team, 1 staff member told us, “The management team we have now are very qualified, MDT team are very qualified, and they are working in house. We have received positive feedback from relatives.” All staff members spoken to, felt the registered manager had good oversight of risks within the service and was actively involved in trying to mitigate and address these with people and staff. The registered manager told us, the values of the home were care, respect, empower, trust and integrity. They told us these were embedded through supervisions and appraisals and the recruitment advert shared the organisations values and there were values-based questions for interviewees. They were able to tell us what systems they had in place to monitor and assess the culture within the home. The registered manager gave us two examples of where they have investigated a concern. Both situations were handled professionally, and learning was taken from them and where appropriate shared with the team. When we asked them, what ongoing professional development and supervision do you receive. They told us, “I am currently doing my level 5 leadership and management. Any help I need, I am given.”

We reviewed the organisations statement of purpose (SOP) which had been updated in May 2024. The SOP contained the organisations aims and objectives. Their vision to provide high quality, sustainable specialist services and their values. We reviewed the provider’s recruitment process which was inclusive. The interview questions were based around the organisations values to ensure right from the start they were employing people with these shared values. The registered manager was currently undertaking an NVQ 5 to support their continuing professional development. A regional quality manager undertakes a yearly cultural visit to the home, where they complete a cultural audit. They spoke to staff on-site and gain their feedback. There is also a freedom to speak up lead, who staff could talk to when needed. Therefore, we were assured the leadership team were capable, compassionate, and inclusive leaders.

All staff members spoken to, felt there was a culture of openness and transparency within the service. 1 staff member told us, “Management are very approachable, if you need support, they are willing to immediately and come and help. They are there and visible, the deputy and the Manager are always there, they get involved in care and lead by example.” All staff confirmed they felt able to approach the registered manager and leaders with any concerns they might have. All staff confirmed they had no concerns about how concerns have been managed by the management team. 1 staff member told us, the manager will seek advice from the MDT if the concern was a specialist concern about a person and the MDT are always happy to help. Staff told us how they were able to make suggestions to improve the service. 1 staff member provided an example where they shared how best to support a person during the changeover of staff, the registered manager listened, and the practise was implemented and used by all staff. The registered manager told us what systems were in place to ensure a closed culture does not develop within the team. They gave us examples of when they had investigated concerns. They were able to tell us what the provider values were. The registered manager was able to confidently explain what duty of candour is and the requirements which need to be met to meet this. They also gave us a recent example of when they had followed duty of candour following a complaint from a relative.

There is a freedom to speak up lead who staff could talk to, when needed. We reviewed a raising concerns / freedom to speak up / whistleblowing policy so were assured staff were encouraged to speak up and how to do this. There was a duty of candour policy in place and during our assessment we reviewed documentation which showed this was being followed . When things went wrong, staff apologised and gave people honest information and suitable support. We reviewed evidence of 3 occasions where practise had changed as a result of concerns being raised. Therefore, we were assured the provider was encouraging a culture of speaking up, being open and transparent and learning when things go wrong.

Staff members told us, their workplace was inclusive, and staff were free from discrimination and there were equal opportunities for all. When asked what support systems were available to you, 1 staff member told us, “For anything that staff are concerned about, they encourage you to speak up and this can be through the speak up group. If you want to, from this group, you can be anonymous. We are encouraged to do this if we would prefer to.” Staff confirmed there were policies and resources on discrimination, support groups for colleagues who were LGBTQIA, disabled, or managing anxieties and they knew how to access them. The registered manager shared with us an example of good practise with regards to supporting staff who might need adjustments. When asked how you make sure staff are aware of your policies around equality and diversity amongst the workforce. The registered manager told us, “We have a policy folder, they are also on our intranet, it is also discussed within the team meeting. We have a disciplinary procedure to follow if people are not treating each other well. We discuss equality and diversity in appraisals and supervisions.” We asked the registered manager, how did you help new starters feel welcomed at the service. They told us, “Just speaking to them kindly and being available for any questions they have. Making sure they have everything they need to do the job.”

We reviewed an equality and diversity policy for staff. We noted recruitment processes were inclusive. We also reviewed supervision and appraisal policies. During team meetings, supervisions and appraisals, staff safety and well-being was discussed. Staff confirmed there were policies and resources on discrimination, support groups for colleagues who are LGBTQIA, disabled, or managing anxieties and they knew how to access them. We reviewed the provider’s recruitment process which was inclusive. The interview questions were based around the organisations values to ensure right from the start they were employing people with these shared values. A regional quality manager undertook a yearly cultural visit to the home, where they complete a cultural audit. They spoke to staff on-site and gained their feedback. There was also a freedom to speak up lead who staff could talk to when needed. The feedback we received from staff were all positive with staff feeling able to speak up and raise anything with the registered manager. We were assured the provider encouraged and promoted a workplace of equality, diversity, and inclusion.

We spoke to staff members about governance, management, and sustainability. When we asked, do you feel valued, supported, and motivated, all staff members spoken to confirmed they did. They told us, the management team was approachable, and supervisions and appraisals were regularly taking place. They told us the provider listened and was willing to help and give the support needed. Staff members confirmed they were able to raise concerns and they were asked for ideas on how to improve the service. They told us, team meetings happen regularly. 1 staff member told us, “Team meetings are held every month. We had one yesterday and we have opportunity to raise any concerns.” We asked the registered manager, how did you ensure all notifications were submitted to the relevant agencies. They told us, “We keep a log in the safeguarding file where we print everything off. In the incident entry there is a box re safeguarding notifications or CQC notifications. If I am on site, I complete them myself. With any safeguarding concerns, staff need to phone me so I can guide them on how to complete the appropriate paperwork.” When we asked the registered manager what they wanted to achieve for people, they told us, “I want the people to have the most normal life you could imagine. I want them to have the same opportunities as you or I, for them to be able to go out whenever they want, and to have community involvement and to be accepted for the great people they are. The registered manager told us how they ensured staff and themselves were following best practise guidance they also told us, how they made improvements to the service. They gave an example of changes they wanted to make to the environment which would benefit the people living in the home.

We reviewed policies and procedures and found these to be in date, reviewed when required and with the correct amount of information and detail. The provider displayed their last CQC inspection rating showed transparency and was in line with our regulations. We reviewed the last 3 team meetings. We noted the team meetings were happening monthly. The first item on the agenda was to discuss the actions from the previous team meeting. We noted discussions were had about people being supported, incident forms, lessons learned, compliments, complaints, safeguarding, training, what had gone well and what had not gone so well. We noted contributions from the staff members attending. We reviewed quality assurance surveys for people which was positive. From their relatives, which was mostly positive and from staff whose results were significantly improved than the previous survey. We reviewed audits were taking place and actions were highlighted and followed up on for example we reviewed improvements had been made to the management of medicines to reduce the risk of errors. We reviewed the business continuity plan which was detailed and included the information expected. Therefore, we were assured staff feel valued and motivated, are able to raise concerns, were asked for ideas on how to improve the service, and team meetings are held regularly, and the provider was meeting the requirements in relation to governance, management, and sustainability.

We were unable to seek the views of people relating to their end of life care. We also did not seek this information from relatives. We saw evidence of 1 person having an end of life plan document in place, however, we reviewed evidence showing their relative had declined to support the staff to complete this.

Staff were able to detail the MDT they worked alongside within the home to support people and the benefit the partnership working had, for example to a person’s PBS plan. Staff were also able to tell us about seeking medical support and advice for people from the district nurse, the GP and from 111 health professionals. We spoke to the registered manager who was able to tell us about who they worked in partnership both internally and externally with. They told us, “We work with a community driver and with relatives. We work with our internal MDT and also work with external MDT. Which includes GPs, neurologists, Learning disability nurses, dentists, and our local funding authorities & CQC.” The manager told us they learned from other organisations by being on mailing lists, signing up for alerts and belonging to the registered manager’s network.

We spoke to 3 professionals about working in partnership, 1 professional told us, “The staff team are much more open to collaborating with external agencies and seeking support and advice as needed. I have seen staff respond to other situations and refer on / contact other agencies in a very prompt manner and collaborate effectively such as seeking medical advice.” Another professional told us, “I believe we have a good working relationship.”

During our assessment, when we raised points with the registered manager, they were responsive and keen to get things right. They also told us they had shared these points with the wider organisation to ensure they were also following best practise. Through reviewing information, observations and talking to staff and the registered manager, we could see evidence of the MDT’s involvement with the people living in the home. We observed the benefits to people and the staff team supporting them, of having this additional support on-site. We reviewed reports which detailed the sessions MDT staff had with people to help them learn new skills of manage their anxieties more effectively. There was continued evidence throughout our assessment of joint working with MDT members including with external members. Feedback from external MDT was mostly positive. Therefore, we were assured staff, the registered manager and the provider were working collaboratively with all relevant external stakeholders and agencies to support care provision, service development and joined-up care.

Staff members confirmed they were asked for ideas on how to improve the service and were able to share examples of this, 1 staff member gave us a detailed account. When asked if they feel there is a focus in the service of making improvements, a staff member told us, “Yes, they are 100 % focused on improvement. The house decoration feels more of a home with a lot more colour. The building now feels like less of a hospital. When asked about learning when things go wrong, 1 staff member told us, “They have an approach where the incident is recorded immediately, they do debriefs with the team and with the resident along with the management team. They get back to you and have lessons learnt and after they have reviewed how it could be avoided, we have listen and learn sessions which are held in a meeting, where they talk about what happened and this helps them know more about what to avoid really. Management don’t blame staff, they want people to learn they are transparent.” Staff spoken to, confirmed they were given opportunities to advance their skills and knowledge. Staff gave us examples of when they had made suggestions as to how things could be done better. 1 staff member told us, “There has been a great improvement in the service. The management have listened and improved. I applaud what management have done which is a great job in improving the service. The home now looks more homely with the colours and cushions added. Residents can sit and eat anywhere they want. They celebrate achievements and they have introduced new things such as a family day. Staff morale has improved, there was a staff appreciation day and were given certificates.”

We asked the registered manager to share with us some improvements they had made, and they gave us some examples. They shared with us how they involved families in the development of the service. We asked them for examples of innovation, and they told us, “I wanted to bring the teams together. We made everything a celebration. We had a staff appreciation day, where we gave out awards for staff. We had a family fun day. When our internal audit came back as good in all 5 domains, we had a party where we celebrated the journey and how far the home had come. We all sat and had dinner together. [Person’s name] cooked lasagne with staff support for everybody.” Therefore, we were assured the service was learning, improving, and showing innovation.