Chilmington House

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 Good. At this assessment the rating has remained Good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 64 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The provider has an Equality, Diversity and Inclusion policy in place and staff have signed after reading it.

The registered manager told us staff were trained and supported in respecting and understanding of people’s different cultures and backgrounds. They also told us they promoted an open and honest culture. Information was shared effectively with staff through daily handovers and regular team meetings. They were aware of the ‘Right Care, Right Support, Right Culture’ framework for ensuring that care should be a choice, person-centred and hold the right values.

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

The registered manager lacked knowledge about prescribing of medicines to people with learning disabilities and had not been fully trained in their role as a competency checker for other staff. They had not completed a 'Train the trainer' course, which would mean that they were assessed as being able to train and check staff competencies, and stated that they had previously approached the overall provider's team for more guidance.

The registered manager led by example and was visible and responsive. Throughout the assessment, they demonstrated a strong knowledge of the people living at the service. It was evident that the service was providing quality, person-centred care.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The provider had created systems and processes, including policies and procedures such as Bullying and Harassment, Declaration to Challenge and Whistleblowing, to support staff to raise any concerns.

Staff informed us they had access to the provider’s policies and procedures and felt confident speaking up when required. A staff member said, “The manager is fair to all staff.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture.

The provider had systems and processes to support and develop an inclusive workforce that respected equality and diversity. Staff received regular and ongoing support through supervision meetings, annual appraisals, ongoing training, spot checks, and staff meetings. Staff were positive about the support they received. The registered manager told us the service did not tolerate bullying, harassment, or discrimination. by improving equality and equity for people who worked for them.

The provider did not always have effective accountability systems, which impacted upon the overall governance of the service. The provider had auditing arrangements in place to monitor the quality of the service, quality assurance and governance arrangements but they were not effective in monitoring and addressing shortfalls in the service.

Care plans lacked adequate communication information especially about signs and gestures which would indicate distress. There was no clear directive for staff on how to recognise different moods and feelings. They also did not have Best Interest Documentation in place. This put people at increased risk of harm since decisions were made without consent.

There were no clear systems and processes in place for adhering to MCA (Mental Capacity Act) principles, medicine management and infection prevention and control standards. There was conflicting information in 1 care plan on SALT (Speech and Language Therapy) adherence. The care plan stated that SALT guidelines directed fluid intake to be a maximum of 200ml at a time, but staff had documented giving 300ml on many occasions. Oxygen saturations had been recorded as 86% with no indication of seeking medical advice for this. NHS guidelines state normal oxygen saturations should be between 95-100%.

The provider’s systems and processes were not robust in identifying and addressing concerns. Although audits had been completed by registered managers from other services, identified issues had not always been acted upon, and the provider could not be assured audit findings consistently reflected the actual condition of the service.

For example, a kitchen audit completed in February 2026 recorded the area as compliant. However, this was inconsistent with findings from audits conducted in January 2026 and March 2026 onwards, which identified concerns within the kitchen environment which put people at risk of harm. In addition, kitchen cupboard doors were missing throughout this period, indicating that the February 2026 audit did not provide an accurate assessment of the condition of the kitchen. This demonstrated a lack of effective oversight and quality assurance processes to identify, monitor and address environmental concerns in a timely manner.

This evidence shows significant shortfalls in the standard of care and people are at risk of harm.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The registered manager recognised the importance of working in partnership to improve people’s outcomes. They described how they worked closely with people, their families where appropriate, and the local authority to support positive outcomes. The home also had visiting healthcare professionals such as a podiatrist.

One professional told us, “They know their clients likes and dislikes really well, such as activities and films they enjoy, and ensure their clients access the community when possible. I have observed them engage well with a family who were visiting their son. I don’t have any particular concerns about this service.”

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

The provider's oversight arrangements required further embedding to ensure positive outcomes and the safety and welfare of the people they supported.

We did not see any evidence of innovation across the service or creative ways in which the provider delivered care to improve the outcomes and quality of life for people who use the service.