Oakdene Nursing Home

We carried out our on-site assessment on 26 and 27 March. Off-site activity started on 28 March and ended on 24 April 2025. We conducted this assessment to review a warning notice issued in June 2024, and to assess safe, effective and well-led key questions. We also assessed one quality statement under caring key question: workforce wellbeing and enablement.

At our last assessment in May 2024, we found risks to people's health, safety and well-being were not always mitigated, people’s risk assessments did not always clearly and concisely describe how to mitigate them. These were breaches of regulation. At this assessment, quality of care plans and risk assessments had improved. Relevant health and safety concerns were included in people’s care plans. However, we found the provider’s approach to assessing and managing environmental risks was inconsistent. We also found safeguarding systems were not fully embedded, and staff had not always recognised when abuse or neglect had occurred nor responded quickly to concerns. There was lack of consistency in how the service was managed. Recent change in management had led to improvements in training and staff support. However, not all staff understood their roles and responsibilities, reporting of incidents, risks, issues and concerns was inconsistent.

At our assessment in May 2024, we found the leadership, governance and culture had not always supported the delivery of high-quality, person-centred care and the provider's monitoring processes were not always effective. Managers did not have full oversight of the service to monitor quality and safety. Staff did not always feel supported, and supervisions did not take place as planned. This was a breach of regulation.

However, at this assessment, we found there had been a continuous lack of consistency in how well the service was managed and led. Since May 2024 there had been several changes of managers. However, staff told us this had led to improvements in training delivery, supervision and the support they received; staff felt more involved, valued and listened to. Governance, accountability arrangements and quality assurance systems had improved significantly. However, management systems were still not always robust and effective in identifying and managing risks to the quality of the service. Audits at the provider level had not always identified the shortfalls found within the inspection.

At our assessment in May 2024, we found people’s experience of the service was not driven by a culture that normalises good wellbeing through inclusivity, active listening, and open conversations, which enables staff to do their job well and to be well. At this assessment, we found vast improvements in the culture of the service, which was positive, person-centred, inclusive and empowering. Culture was shaped by engaging with staff, people who use services, carers and other stakeholders. Managers and leaders genuinely welcomed feedback and demonstrated what action has been taken in response. People were involved and consulted about their care and reviews of concerns.

The provider remains in breach of the regulations relating to safeguarding people from the risk of abuse, including consent to care and treatment, and the management and oversight and governance.

The provider engaged with CQC and local authority. We asked the provider to submit action plans for the areas in breach of regulations.