Cholwell House 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 questions good. At this assessment the rating has remained as good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care. The service was in breach of the legal regulation in relation to governance. The provider’s governance systems did not identify the shortfalls identified in this inspection; however, we noted the provider took prompt action to address the concerns and sent CQC evidence of actions taken.

This service scored 62 (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 manager said they had involved staff with a discussion about the key values of the service. Leaders were aware of the risk of closed cultures forming in teams and took steps to prevent this by ensuring staff moved around the service and get to know all the people using the service and to work alongside different team members.

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 did so with integrity, openness and honesty. There was no registered manager at the time of the inspection, however we were told by leaders there were plans for the manager to register with CQC.

Staff told us the manager was “supportive” and “approachable.” One staff member said, “[Manager] has got the residents’ best interests at heart. I have a lot of respect for her and the way she looks after the residents, the staff and the families. It works. She's very personable. She's also very clever and is good at moving things forward.” Staff told us the management team were also supportive. They said they were able to call a member of the management team at any time for advice.

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

Processes were in place to support staff to speak up. Leaders told us they encouraged staff to speak up through regular staff meetings, supervisions, staff surveys and being available in the service for staff to approach.

Staff told us they felt confident to speak up and raise any concerns about care provision. Staff knew who to speak to and felt able to go higher in the organisation if needed.

The provider valued diversity in their workforce. They had an inclusive and fair culture which had improved equality and equity for people who worked for them. Leaders told us how they celebrate and recognise their diverse workforce, for example holding an ‘African day’ organised by staff with an African culture to help staff and people at the service to understand different cultures. We saw staff had shared information about their culture and this was displayed in the service. One staff who had come from overseas said they felt very supported by leaders in their role.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance.

The manager had recently introduced a range of new audits to provide oversight of the service and people’s health, for example repositioning audits and wound audits. However, these processes had not been implemented and embedded effectively and had failed to identify and address issues identified in this inspection in relation to care plans and the environment.

The provider took action to make improvements immediately when the concerns were raised by CQC, and we saw evidence of these improvements following our onsite visit. Regular meetings were held to ensure staff and leaders were aware of changes in people’s needs.

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. Partners confirmed the service regularly contacted them for support and queries were dealt with promptly. One partner said, “Activities have improved, for example a vintage motorbike event was arranged for a resident who was an ex-biker, and they have strengthened their links in the community in the last year.” We were told members of the local church come into the home regularly to sing and do activities with people who wish to join in.The service partnered with the local fire service to support staff training and familiarisation. The provider also regularly promoted activities on social media, inviting the local community to take part.

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.

Leaders told us how they had shared learning with partners and, as a result, a health partner had made changes to their staffing structure to provide safer medicines management for care homes.Leaders reported that staff were given time to develop their skills, which was confirmed by staff feedback. The provider funded a coaching programme to support the manager in implementing service improvements. The manager actively shares best practice through care home forums, published articles, and podcasts, contributing to adult social care. Additionally, the service had introduced an innovative method to collect visitor feedback and promptly alert leadership to any concerns raised.