Chandos Lodge Nursing Home

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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate.

This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to governance at the service and failure to submit notifications.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities

Leaders did not demonstrate capability or openness required to promote high quality care. Audits were undertaken internally by the registered manager with limited evidence of independent scrutiny of these audits to promote an open culture and ensure auditing was effective in identifying and improving the service culture and promoting a positive, person-centred environment

Some staff employed were closely related to the provider, with no risk assessments completed to identify conflicts of interest and had the potential for a lack of transparency and reduced openness within the service. Alongside this, the service failed to submit required safeguarding notifications to CQC and the local authority safeguarding team. Your lack of external reporting to CQC and the local authority safeguarding team indicated a lack of transparency and external oversight which did not promote an open culture.

This limited reflection within leadership and a culture that did not consistently promote openness, learning or continuous improvement.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

Relatives, professionals and staff described leaders as approachable, personable and compassionate. However, we found the service was not safely managed placing people at risk. The provider and registered manager had delegated day to day management to a staff member who while personable and well regarded, lacked management skills and knowledge of regulations, including the Health and Social Care Act. They also failed to follow multi- agency safeguarding procedures and the service’s own policies. As a result, leadership failed to ensure care was consistently safe, effective or compliant contributing to a closed culture and a service that was unsafe and in breach of multiple regulations.

Systems were not in place to promote speaking up.

The service had an out-of-date whistleblowing policy in place, with no evidence of a recent review. Staff told us they would raise concerns internally, however they were unable to describe how they could escalate concerns externally to relevant bodies such as the local authority safeguarding team. This limited staff confidence to speak up externally and reflected the service’s closed culture, reducing opportunities for independent oversight and challenge.

There was no formal system in place to routinely seek feedback from staff or other stakeholders. The provider acknowledged this and agreed to introduce a staff survey as a way of capturing feedback and identifying areas for improvement.

The provider confirmed relatives were sent surveys asking for feedback and provided us with evidence to show this. However, one relative told us they had never been asked to provide feedback on the service. This indicates that systems to routinely capture and use feedback was not fully established.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The service had a diverse group of staff employed, with systems in place to support them with their religious and cultural needs.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider had some governance systems in place, including audits of care plans, medicine managements and monthly provider visits. However, these audits were ineffective and did not identify the shortfalls found during the inspection.

Records of provider visits carried out by the registered manager demonstrated a focus on observations and minimal feedback from people and staff, with an over reliance on information provided by the manager in day-to-day charge rather than independent verification. For example, during supervision of the manager the provider recorded that the service was compliant with CQC regulations and local authority safeguarding requirements, despite not having audited or verified this, and the inspection evidence demonstrated this was not the case. The lack of independent oversight, combined with ineffective monitoring meant that issues affecting care quality, safety and compliance were not identified or addressed.

Record management systems were not effective. Records were not consistently organised or readily available, with some staff records stored off site and not accessible during the inspection. People’s care records contained contradictory information about people’s needs and risks, including the frequency of checks, continence needs, support required with repositioning and recorded weights used to inform moving and handling guidance. We also found examples where information related to one person had been recorded in another person’s care records, which further demonstrated that records could not be relied on upon to accurately reflect people’s care and support needs. Terminology used in people’s records was not respectful, person-centred or in line with best practice, with people described using terms such as ‘wandering’ or ‘attention seeking’. In addition, people’s records were not always completed such as moving and handling risk assessments, and mental capacity assessment records. These issues demonstrated that the provider did not have effective systems in place to maintain oversight and ensure records were accurate, complete and appropriately maintained to mitigate risks to people.

Staff records were not accurate or complete. The staff rotas did not reflect the staff on duty, and the training records did not include all staff working in the service. This meant there was no effective oversight of staffing arrangements or staff training.

Policies were not consistently up to date or in line with recognised best practice and staff were not always following them. For example, the safeguarding policy was not in line with local authority procedures, and the missing persons policy did not refer to the Herbert protocol (a nationally recognised tool to support a timely response when a person goes missing). The whistleblowing policy was out of date, and staff were not following the fire policy in relation to the frequency of fire drills. This meant the provider governance systems were not effective in ensuring staff compliance with policies or that policies were up to date and reflected current best practice.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.

The provider failed to work effectively in partnership with external agencies. Staff were routinely subjected to verbal and physical abuse from people they supported, which had become accepted as part of the day-to-day practice within the service. There was limited reflection of these incidents, and they were not systematically analysed or escalated. The service did not identify safeguarding risks or make appropriate referrals to the local authority safeguarding team and other professionals who might be able to provide additional support and guidance. This demonstrated a systemic failure to work collaboratively with key agencies to ensure people’s safety and well-being.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

The service did not have effective systems in place to capture, analyse and use information from incidents to support learning, improvement and innovation. In addition, the provider had not submitted required notifications to CQC. These included a notification of a serious injury that resulted in a person being admitted to hospital, as well as notifications relating to safeguarding’s and Deprivation of Liberty Safeguards (DoLS). This meant opportunities to identify patterns, learn from incidents and make improvements were limited, reducing the services ability to enhance the quality and safety of care for people.

The provider had also been in breach of Regulations 12, 17 and 19 at previous inspections indicating that lessons from previous regulatory findings had not been effectively learned or acted upon.