Welcome House - 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

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 changed to Inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to good governance.

This service scored 29 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was a closed culture at the service. A "closed culture" is a poor culture that can lead to harm, including human rights breaches and abuse. We found a poor culture across the service, which had an ongoing detrimental impact on people’s safety and well-being: this had not been recognised or addressed by the registered manager or provider. The registered manager and provider did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The registered manager and staff told us they had a clear shared vision. However, this did not transfer into reality for people living at the service, and we found widespread concerns regarding people’s safety, including people experiencing being harmed. Leaders and staff did not always understand the challenges and the needs of people so they could ensure this was embedded into their daily practice so people were given the best opportunity to living fulfilling lives

Staff told us, “We work well together and the team is supportive of each other. We are here to help support and encourage people to be as independent as possible.” However, we found that people were not receiving person-centred care that offered variety, meaningful engagement, or opportunities to learn new skills to support their progress and enhance their quality of life.

The provider did not have leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their organisation.

Staff said the provider visited the service regularly and that if something needed to be, “sorted” it was done. A staff member said, “I do feel valued here.”

Despite this, we found the registered manager and staff had not considered ways to give people more support to help them to achieve their goals and aspirations. The provider had fostered a closed culture within the service, where safeguarding concerns were managed internally rather than being appropriately escalated and insular practices limited transparency and accountability.

In addition, the provider had supported staff to work exceptionally long hours without adequate breaks. This placed staff at risk of fatigue and stress as well as increasing the likelihood of mistakes happening. It also meant people were at risk of receiving care from staff who were too tired to perform their roles safely and effectively.

The registered manager did not understand their role as a registered person as they had failed to notify CQC of incidents, accidents or safeguarding concerns which is a requirement of registration.

Staff felt they could speak up and that their voice would be heard. Staff told us, “I feel I am listened to. If nothing is done about concerns, I would speak to head office.”

Despite staff telling us this and that their voice would be heard, we found a poor culture in which institutionalised practices went unchallenged by the provider, leaders and staff. The registered manager told us they listened to staff concerns, and staff confirmed this. However, we could find no records of any concerns being raised regarding the issues we found at our inspection, and leaders and staff displayed no insight into how a perpetual culture of people’s concerns about their safety and well-being were not listened to.

We found no evidence of positive action being taken to improve people’s lives: the registered manager told us “I have 1 to1 chats with staff. I ask them if they have any problems and they can call me at any time. I pop in at weekends to check staff are okay.” Although this demonstrated the registered manager listened to staff and checked they were ‘okay’, there was no focus on people, or a recognition that people relied on staff and leaders to advocate for them when they themselves were unable to.

Although the registered manager told us they valued diversity in their workforce. They were unable to give us any real example of how they, as the registered manager ensured inclusivity and fairness. This was demonstrated through the on-call arrangements within the service which we identified through staff rotas. This meant that on alternate weeks 1 staff member worked long hours between a Monday and Friday and were on call for the whole 7 days of that week. The registered manager had no pursued different options of sharing the on-call amongst the rest of the staff team or with staff of some of the provider’s other services which did not reduce pressure on individual staff.

Staff however felt the registered manager recognised diversity within the team. One told us, “If I needed adjustments, I am sure they would be in place. We have had staff before who were Muslim and they were supported to pray whilst at work.”

The registered manager told us, “We don’t discriminate; we treat everybody equally. We have different cultures within the staff team and different cultures within the service users.”

The registered manager did not have clear responsibilities, roles, systems of accountability or good governance.

We identified shortfalls in the governance arrangements during our last inspection and although the provider told us of the improvements they would make, we found this had not been done. Despite audits being carried out and staff keeping ‘check lists’ we found these were not being filled in accurately. For example, the cleaning check lists had not identified all the dirty areas in the service. We saw the provider’s QA (quality assurance) manager had written in their June audit, ‘pull cords need cleaning’, we found on our first day of inspection they were dirty. In addition, neither the provider’s QA manager nor the registered manager had identified through their monthly audits the inappropriate condition of the garden with the unsuitable items in it.

The provider’s action plan from our last inspection stated they would improve the opportunity for people to go out and yet, we found this had not happened. People still remained at risk of social isolation and without the support to attend activities or participate in pastimes meaningful to them.

In addition, although the provider’s QA manager had identified in July that in-depth cleaning of carpets were required in the service and gave a deadline of the following day, when we arrived on our first day of inspection on 12 August, we found this had not happened. We also read that the QA manager had identified on 2 consecutive months the registered manager had not completed their internal audit, despite being reminded to do so.

The registered manager told us on our second day, “I have cleaned the house from top to bottom since your visit and cleared the rubbish from the garden. The decorator is coming tomorrow to paint all the internal walls. I identified all of these areas from my last audit. I gave the maintenance man a list yesterday.” However, when we reviewed their audit, it was dated 4 August 2025 and stated, ‘house deep cleaned’. Yet we visited 8 days later and found this was not the case.

We also looked at the list given to the maintenance person and noted this had not included the cracked bathroom window, missing bath tap cap or chipped bath enamel.

We read the registered manager carried out unannounced out of hour checks. However, they did not maintain robust notes from these as we saw in one they had written they arrived at the service at 07:40 but left at 07:30.

The registered manager did not understand their duty to collaborate and work in partnership, so services worked seamlessly for people.

The registered manager told us, “We work with health care professionals and some people go to church on a Sunday. We encourage everyone to attend church.” We asked about opportunities for people to engage in local groups or activities and they told us, “There is a day centre in Gillingham, I am going to look at the activities there for people and there is another group (I can’t remember the name) and I am going to try and get them in there.”

In addition, we asked about the opportunity for people to go out in the evening, for example to the pub or the cinema. The registered manager told us, “People don’t drink. They just don’t like going out at night. But I can arrange for the cinema – that’s a good idea.” This was despite one person telling us they would like to go for meal in the evening to their favourite restaurant.

This showed opportunities for people to engage in local groups were not already identified or embedded into daily practice. It also demonstrated a lack of will for staff to look at ways of working in partnership with the community for the benefit of people.

The provider and senior staff did not focus on continuous learning, innovation and improvement across the organisation.

We asked the registered manager what changes had taken place to improve the service following our last visit. They told us, “Rooms have been decorated. We are doing more stuff with the residents and we have had a whole new staff change. The [provider’s QA] redeployed all staff around the other homes and we had a whole new staff team.” We asked if people were included in any consultation around this and the registered manager confirmed they were not.

Despite the provider sending us their action plan following our last inspection telling us how they planned to address the shortfalls, we found they had failed to make the required improvements.