Archived: The Chestnuts

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 remained Requires Improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider was previously in breach of legal regulations in relation to good governance about accurate and up to date records. Improvements were not found at this assessment, and the provider remained in breach of this regulation. In addition, ​the provider was in breach of the legal regulation relating to informing the Commission of certain events.

This service scored 50 (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 clear mission statement which was communicated to staff. The policies and procedures at the service were written to promote a culture focused on learning and improvement.

We did not always see that people’s care reflected high quality and best practice guidance. For example, the provider did not routinely follow National Institute for Health and Care Excellence (NICE) guidance for medicines practice.

Staff meeting minutes did not refer to the visions, values and strategic goals of the service, which meant there was a lack of shared direction between managers and workers. Quality audits and action plans were designed to focus on learning and improvement but these did not always identify the deficiencies we found during our assessment, such as continued breaches of regulations.

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.

People lived in a care home which did not have a registered manager in post. The provider had appointed staff into the position of a manager however, there had not been stability at the service. People, their relatives and staff had commented on this.

People and their relatives told us they were not sure who the manager was, although they knew there had been a recent change. Comments included “They have a new manager, I don’t know her name”, “I have met the manager, but I can’t remember her name” and “I don’t know who the manager is, I met her for the first time on Saturday, I stopped her and actually asked her who she was”.

Comments from other relatives referred to poor communication about management of the home. We were told “Most of the time they seem to have been managerless, we are not told officially who is in charge” and “I know where her [manager] office is, but she never speaks to me, never”.

Since our on-site visits there had been a further change in management at the home. We have asked the provider to ensure changes regarding management are communicated with people and their relatives.

People did not always feel they could speak up and that their voice would be heard.

People gave us mixed feedback about how they felt about speaking up and being listened to. Some people told us their voice would be heard, they had opportunities to attend meetings with staff. However, other people told us staff did not always have time to speak to them. We observed this on the second day whilst at the service. One person asked to speak with staff, the staff member said “later”, we did not observe they [staff] went back to the person. One person told us “I don’t know how to improve my life here, the carers don’t have the time to talk really”. A relative told us “I would trust many of the current carers but there are others who never communicate or talk to me”.

Staff told us they were aware of how they could speak up. The provider had policies and procedures in place for staff to raise confidential concerns.

Staff we spoke with told us how they had been supported to take on new roles and responsibilities within the home. One member of staff told us they were valued as they had support from the management team and had opportunities for training and career development.

People were support by a diverse group of staff which represented the local community.

The provider did not have clear systems of accountability and good governance. They did not always act on the best information about risk, performance and outcomes. Records did not always reflect the current needs of people. For instance, people who were prescribed medicines to prevent seizures, did not have care plans in place to tell staff about potential seizures. Care plans for people with diabetes, did not routinely advise staff on what to look for when blood sugars were high or low. The provider’s policies and procedures had not always been updated when identified by them. We found delays or omissions in risk assessments and care plans being written when changes to people’s circumstances, to reflect the changes in their care needs.

The provider’s auditing systems did not always identify the issues we found, for instance, the concerns about how prepared staff were for an emergency. Systems were not effective in ensuring medicines records met best practice standards.

Systems were not effective to ensure we were notified of all relevant incidents, and that this was done “without delay”. The local authority had investigated 13 safeguarding concerns under The Care Act 2014, we had not been notified of all these allegations of abuse.

The provider understood their duty to collaborate and work in partnership. The provider made timely referrals to external parties when needed. They shared information with partners and collaborated for improvement. The provider had been working with the local authority on an improvement plan to ensure people received safe care and treatment.

People were supported to continue to be part of the community. People were given the opportunity to attend garden centres, theatre, coffee shops and restaurants. In addition, the home visited other residential care homes under the Forget-me-not scheme, which aims to connect people with others from the local community.

The provider did not put sufficient focus on continuous learning, innovation and improvement at The Chestnuts. They did not actively contribute to safe and effective practice. We saw some examples of making improvements and learning when things went wrong, however, these were not always followed up to ensure the action had been put into practice.

The provider’s quality assurance systems were not used effectively to continuously improve the service. They had not consistently recognised risks to people’s care and ensured measures were put in place to prevent harm. Although the provider put an action plan is place following the last inspection, learning had not taken place and there were continued breaches of regulations.