South Chowdene

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 the last inspection we rated this key question outstanding. At this inspection 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. 

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 very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an understanding of the challenges and the needs of people and their communities. Staff and relatives described improvements since the appointment of a permanent manager, noting a more positive and collaborative atmosphere. People told us they felt listened to and respected, and staff demonstrated a commitment to delivering person-centred care. However, feedback highlighted that previous instability in management had affected morale and continuity of care. The new team was working to embed consistent standards and maintain a culture of accountability. One relative told us, “The new manager is very approachable and efficient.”

The new management team were visible, approachable and described as supportive by staff and relatives. Over recent years there have been 6 changes to the registered manager, with the current manager only being in post for a few months. The new registered manager had taken swift action to address gaps in care records and medication processes, demonstrating responsiveness and integrity. Staff spoke positively about recent changes, reporting improved morale and clearer communication. While some staff previously felt excluded from decision-making, most now felt involved and optimistic about the future. A staff member told us, “I was considering leaving but since [registered manager] came on board I changed my mind because I know we can change a lot. We have changed a lot because now everyone is putting the effort to improve things.” Leadership changes have strengthened confidence in the service, though registered manager understands further work is needed to ensure staff morale continues to improve.

The registered manager fostered a positive culture where people felt they could speak up and their voice would be heard. People, relatives and staff told us they felt confident to raise concerns with the registered manager and these would be listened to and acted upon. Regular meetings and handovers provided opportunities for discussion, although some staff reported their suggestions had not always acted upon but felt this was improving now the new management team were in post. One staff member said, “If I have any concerns, I raise them immediately and make sure they are dealt with.”

The provider valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. The provider and registered manager valued diversity and ensured they followed best practice guidance.

Governance systems were not always effective in identifying and addressing risks promptly. Audits of medicines and care records had not detected issues we found during inspection, such as gaps in MAR charts and unclear codes. While the new management team acted quickly to resolve these concerns, oversight of the service needed to be strengthened to ensure sustained compliance. Roles and responsibilities were clear, but the staffing pressures and reliance on agency staff in the past have impacted service resilience. The new management team at the service swiftly addressed these issues and raised them with the senior management team. Going forward the management team’s ability to robustly scrutinise performance at the service, learn lessons and implement changes will ensure these systems become more effective.

Staff worked collaboratively with healthcare professionals to support people’s needs. Visiting professionals praised staff knowledge and communication, noting improvements in ward round arrangements that enhanced care safety. Relatives reported that staff were responsive and approachable, and the home maintained positive relationships with families. One professional said, “During the last 6 months both myself, and the GP have seen a significant improvement which has led to overall better care and treatment for the residents.” Relatives reported that staff were responsive and approachable, with one stating, “If I have had any concerns regarding her care there, I have felt at ease talking to members of staff regarding concerns and they contact me back about resolving the situations.”

The management team had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They demonstrated a commitment to learning and improvement. Incidents and safeguarding alerts were reviewed, and lessons learned were shared with staff. Staff described a stronger learning culture under current management, although some felt online training did not fully meet their needs. The new management team promoted continuous improvement and planned to enhance training by introducing more face-to-face sessions for staff.