Chesford Grange Care 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

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

The provider was previously in breach of the legal regulation in relation to good governance. Enough Improvements was found at this assessment, and the provider was no longer in breach of this legal regulation.

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 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.

Staff spoke positively about the registered manager and deputy manager and felt they had the skills, knowledge and experience to lead the service effectively. One staff member told us, “The manager and deputy manager have strong leadership skills and good clinical knowledge. They lead by example, support staff development and promote high standards of care, which gives me confidence in their ability to lead the service effectively.”

Management were visible and approachable, and staff felt comfortable raising concerns, sharing ideas and seeking support when needed. Regular meetings, supervisions and daily handovers provided opportunities for staff to discuss people's care, learn from incidents and contribute to improvements within the service. This helped create a shared understanding of the provider's vision and expectations for delivering person-centred care.

Leaders demonstrated compassion towards people and staff, and their values-driven approach promoted trust, collaboration and a positive culture across the service.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They always did so with integrity, openness and honesty.

People and relatives spoke positively about the leadership team. One relative told us the manager was approachable and they felt confident any concerns raised would be addressed promptly. Another relative told us, “[Registered manager] and [deputy manager] are great, nothing is too much and they always have time for you.” Staff were also positive about the impact the registered manager and deputy manager had made since the last inspection. One staff member told us, "The registered manager is extremely approachable, kind and caring." Another said, "There have been lots of changes for the good. I feel confident in my day-to-day job."

Staff told us they felt listened to and encouraged to share ideas and concerns. One staff member said, "Everyone is encouraged to speak when they have an idea, when they have a concern, or just because they want to share something."

The registered manager was visible within the service and regularly engaged with residents and staff. They demonstrated a clear commitment to improving the service and ensuring people received safe, effective and person-centred care. Their leadership had driven improvements since the last inspection and helped create a positive and supportive culture within the service.

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

Staff reported feeling comfortable and confident they would be listened to. One staff member said, “The registered manager was approachable, supportive, and operated an open-door policy.” A whistle-blowing policy was in place and readily accessible to all staff members, ensuring transparency and accountability within the organisation.

The provider valued diversity within the workforce and promoted an inclusive and fair culture. Staff were encouraged to understand and apply the home's values in their day-to-day roles.

Staff told us they felt treated fairly and supported by the management team. Regular meetings, supervisions and day-to-day discussions provided opportunities for staff to share their views and contribute to the development of the service. The provider promoted a culture where individual differences were respected, and staff were encouraged to value people's diverse backgrounds, experiences and preferences.

The provider had introduced the home's values into their electronic care planning system, to ensure they remained visible and embedded in practice. A different value was discussed each month during staff meetings, where staff were encouraged to reflect on what the value meant to them and how they demonstrated it in their work. This helped staff consider how they could promote dignity, respect, equality and inclusion when supporting people and working alongside colleagues.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The provider had made improvements since the last inspection, where concerns had been identified in relation to staff competence, clinical staffing levels, health and safety checks, the management of restrictions and statutory notifications. The provider had implemented systems and processes to improve oversight, monitor performance and drive improvement.

The registered manager demonstrated a clear commitment to ensuring the service was safe, effective and a positive place for people to live. They spoke with passion about the service, the residents and the staff team.

The management team used a range of governance systems to identify and respond to risks within the service. This included regular clinical governance meetings, audits, feedback from people and relatives, and reviews of accidents and incidents. Staff told us risks and areas for improvement were discussed through handovers, staff meetings, supervision and daily 'flash' meetings. Focus topics were identified each week, such as falls, mealtime experiences and audit findings, to promote learning and improve outcomes for people.

The registered manger and deputy manager demonstrated an understanding of their regulatory responsibilities and the importance of reporting and escalating concerns appropriately. Records showed audits were completed, actions were identified where improvements were needed and progress was monitored.

Governance arrangements had improved since the last inspection and provided a greater oversight of quality and safety within the service, helping to drive and sustain improvements.

Please see peoples experience in the commentary summary.

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 provider worked effectively with a range of external professionals, including social workers, speech and language therapists, physiotherapists, GPs and dietitians. These relationships supported timely, coordinated and responses to people’s changing needs.

Professionals spoke positively about their experiences of working with the service. One professional told us, “I have a good relationship with Chesford and regular communication. I would say they are very good and familiar with the residents. I can say that if they believe there is a risk in a resident’s condition, they contact me as soon as possible to arrange for a visit.”

Records confirmed regular communication and information sharing with external professionals. Recommendations from professionals were incorporated into people’s care and support, which helped to ensure care remained consistent and responsive. This collaborative approach supported joined-up working, reduced delays and improved outcomes for people.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Staff told us they felt valued and engaged in the improvement process. Lessons learned were shared openly, creating a culture of reflection.

The provider had made improvements since the last inspection. The registered manager and deputy manager focused on continuous learning, improvement and innovation across the service. They promoted a culture of reflection and learning, encouraging staff to build on their skills and contribute ideas to improve people's experiences and outcomes.

Staff told us they felt valued and involved in the improvement process. One staff member said, "I feel that staff views are valued and considered when looking at ways to improve the service." Staff also told us lessons learned were shared openly, creating opportunities for reflection and improved practice.

The management team used audit findings, incidents, accidents and safeguarding concerns to identify learning and drive improvement. Staff told us they were regularly updated on outcomes and actions taken, which supported shared learning across the service.

The provider had demonstrated learning from previous concerns and had implemented systems to support ongoing improvement, resulting in better oversight and outcomes for people.