OSJCT Chestnut Court

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 71 (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 shared their vision and strategy with managers and staff when they first started work for them. The provider promoted and supported an inclusive culture so people, their representatives, staff and the wider health and social care community, could work collaboratively to achieve better outcomes for people.

Managers and staff were provided with training and ongoing support to develop and improve their knowledge in relation to equality and equity in care and to manage the challenges which can arise in achieving this. Staff also received training which supported them to uphold people’s human rights when in care.

The provider had arrangements to monitor progress and success against its own strategies and goals and those of the wider adult social care community. Where there were risks to these not being met, action was taken to reduce and mitigate these risks.

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.

In the absence of the registered manager the provider had ensured the service was supported by capable managers. The managers present during this assessment held qualifications in management and leadership and understood the service’s challenges. They were aware of the provider’s expectations and CQC’s regulatory requirements.

These managers upheld the provider’s values and were skilled at promoting and supporting an open and inclusive culture. Staff told us this culture had not always been promoted by all leaders in the service. However, changes were being made, and they told us they felt supported.

Managers were visible and staff found them to be approachable. They had worked alongside service leaders making changes, which had provided leaders with clarity regarding their roles and responsibilities. This had resulted in a more equitable way of working. Leaders were visible and seen to be supporting staff.

The provider identified staff development aspirations and abilities through individual staff supervision sessions. They actively encouraged and supported staff to develop their careers by funding external courses and training which led to additional qualifications. This included, nationally recognised care affiliated courses and management courses, such as the Skills for Care, Succeed to Lead programme for aspiring managers.

The provider had arrangements to support speaking up although staff were not always confident their voice would be heard if they spoke up.

At the time of this assessment, we did not observe any obvious information pertaining to or promoting speaking up. There was no speak up champion in the service to provide a point of contact for staff or to promote a culture of speaking up.

Some staff told us it had been difficult to speak up and be heard. However, these staff told us the culture was changing, and that the managers present at this assessment, were open to listening to their feedback and acting on this.

A member of staff said, “I go to [manager] they have a listening day on a Tuesday, otherwise I email them”. Another member of staff said, “I would feel comfortable to raise any concerns and speak to whichever senior manager was in on the day.”

Managers told us the provider had arrangements to provide staff with opportunities to speak up. These included ‘listening events’ which the provider organised within the care home. A manager said, “Listening events are at least annually and depends on what is happening in the home.” They explained there had been 3 events held in the last year at Chestnut Court with staff from the provider’s Human Resource team also in attendance. They told us weekly listening events continued to be held.

Regular staff meetings and individual staff supervision sessions were held where issues or concerns could be discussed.Concerns raised by staff had been reviewed and were being addressed.

All staff we spoke with were aware of the provider’s whistleblowing procedures and were confident concerns raised about poor practice were listened to and acted on.

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 provider’s policies and values promoted and supported an inclusive and fair culture where a diverse workforce was celebrated, and staff had equal opportunities to develop and flourish. OSJCT Chestnut Court had a diverse workforce which the managers supported and valued.

All staff completed training which widened their understanding and knowledge of equality and diversity. This included modern slavery training which supported a wider workforce awareness of what a fair and inclusive workforce culture looked like.

There were arrangements to support staff with needs which arose from their protected characteristics. There was evidence of reasonable adjustments having been made to support some staff.

There were arrangements to support staff with additional learning needs, including staff employed from overseas where English was not their first language. A manager said, “We adapt training for overseas staff to allow for more room for discussion” (meaning more time for questions and clarification to support understanding).

These arrangements ensured staff had equal opportunity to complete necessary training which supported their future development and career progress.

Staff achievements were recognised and celebrated.

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 extensive systems and processes to monitor the service’s performance. The provider’s quality team had completed quality assessments and their findings had been shared with the provider and the registered manager. This information told the provider and registered manager, where the service was performing well and where improvement was needed.

Information from these quality assessments, along with information from the provider’s programme of audits, helped to inform the service improvement plan (SIP). Progress on the SIP was monitored by the provider.

We saw actions had been completed and new actions had been added, which included work to be completed on care plans. A manager said, “This is my bible to knowing what needs to be achieved and what has been achieved.” The same manager had already identified the need to review the Deprivation of Liberty Safeguards (DoLS) matrix to assure themselves that the information held was correct and there were no outstanding actions to take.

The provider had processes to monitor risks and managers had clarified with leaders, roles and responsibilities relating to the management and monitoring of clinical risks. During the assessment they confirmed the introduction of an additional weekly meeting. The purpose of this to review accidents and incidents as well as existing and new clinical risks so managers could assure themselves that all necessary actions, in response to these, had been taken. This was in addition to a monthly monitoring process already in place.

The provider sought feedback from people and their representatives to support their improvement plans.

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 service worked in collaboration with commissioners of care, and health and social care professionals, to support a seamless approach to people’s care journeys.

Arrangements and working relationships with partners supported people’s transfers into the care home from hospital or back to the person’s own home. Information was shared appropriately between the service and partners to support seamless transfers of care and discharges.

The service had links within the community which it wanted to extend. This included collaborative working with local children’s nurseries and schools to support a better understanding and connection between older and younger people in the community.

The service had links with other community partners which had resulted in the care home supporting projects which benefitted the local community. This had included a contribution to Remembrance celebrations in 2024.

The care home had benefitted from these community links during the hot weather when bottled water and ice lollies had been donated to people in the service by a local community partner.

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.

The provider had continuous improvement strategies. A manager said, “There is a designated team of people behind the scenes making things streamlined.” They confirmed the provider invested in technology which improved the service’s ability to operate more effectively.

The provider had upgraded the internet connection to support digital systems such as, the implementation of digital care records and the planned introduction of EMAR (Electronic Medicines Administration Records).

The provider had invested in improved systems for data collection and analysis. This supported the provider’s longer-term strategic planning, business planning and allocation of resources to support its services. Managers at the service used this system to produce reports which helped them analyse data to assess the service’s performance against the provider’s key expectations and improve outcomes for people.

The provider had funded a significant refurbishment of the service. A manager said, “Since this we've seen [staff] take more care and pride in the home. We can't expect people to respect the home if it's not maintained.”

The views of people and their representatives were sought. The service improvement plan (SIP) included actions to improve the environment as a result of people’s feedback.

The provider and managers of the service were part of local and national forums which helped them remain updated with current practice and innovations.