Chacombe Park

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• 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

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 well managed and governance arrangements supported safe, effective and compassionate care. Leaders were visible, approachable and engaged with staff, people and relatives. Staff described the team culture as supportive and inclusive. A range of audits and checks were carried out, and where issues were identified, prompt action was taken and monitored. Leaders encouraged learning and improvement, and staff and families said their feedback was valued.

This service scored 75 (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. Staff told us they felt part of a supportive team and described the home as “like a family.”

Daily meetings with heads of departments provided leaders with an overview of the service and ensured key information was shared with staff. Leaders also encouraged staff to contribute ideas and suggestions about how to make care more effective, which staff said made them feel valued. We found there was a positive learning culture, and staff said they were comfortable raising concerns, knowing they would be listened to. Lessons from incidents and safeguarding were shared openly with the team so that improvements could be made. Relatives also confirmed the service had a calm and welcoming atmosphere, and one told us their family member was “safe, happy and well looked after.”

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.

Leaders were approachable, visible and engaged with people and staff throughout the home. Relatives said they had confidence in the leadership, with one relative telling us, “We notice that he is always wandering around the home and checking things out, it is clear that he is proud of the home.” The provider, leaders, managers and staff were described as passionate about making the home welcoming and homely. Feedback we received from people about how the service was managed, was positive.

Leaders had the skills, knowledge and experience to deliver effective care and were supported by the provider to maintain this. They understood their responsibilities and kept up to date with relevant changes, notifying CQC as required by law. Records showed that leaders monitored care quality through audits and acted promptly when shortfalls were identified, which gave assurance that issues were addressed quickly. Staff told us they felt supported and able to share ideas about how the service could improve.

The provider fostered a positive culture where people felt that they could speak up and their voice would be heard. Staff, managers and leaders supported people to speak up and raise concerns without fear. They did so with empathy and compassion.

Staff told us they felt confident raising issues and knew how to use the whistleblowing process if needed. They said concerns would be taken seriously and acted on, and if necessary, could be reported externally to the local authority or CQC. A speak upChampion was in place to support openness and provide staff with a safe point of contact. Staff also told us they felt listened to in meetings and supervisions, and that their suggestions were welcomed by leaders. The provider also held meetings with people and their relatives, giving them a regular opportunity to share their views and raise concerns in an open forum.

The provider valued diversity in their workforce and worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Leaders promoted an environment where staff felt respected and treated fairly, regardless of their role or background.

The provider employed staff from a range of diverse backgrounds, with strong skills and knowledge, which enriched the service. Staff told us they were positive about their job roles and said they felt supported and treated equally. They also had equal access to training and development opportunities and were encouraged to progress in their careers. Staff said they felt comfortable raising concerns and confident they would be listened to.

Regular staff meetings gave them the opportunity to share their views, and the provider also held meetings with people and their relatives to ensure everyone’s voice was heard. Leaders encouraged openness and inclusivity, which contributed to a positive team culture focused on providing good care.

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’s quality processes and systems were used to monitor all aspects of the service. These included audits and checks to monitor if people were treated with kindness, compassion and received safe care. The provider and managers completed a range of audits and observations covering medicines, infection control, care plans, health and safety and the environment. We reviewed a sample of completed audits and saw that where issues had been identified, action had been taken, and leaders monitored the progress of improvements. For example, when a shortfall was found in PRN protocols, this was immediately corrected, and staff were reminded of best practice.

Leaders also acted quickly when concerns were raised, including addressing environmental issues such as oxygen signage and storage practices. Families gave positive feedback about how the service was managed and said leaders were approachable and responsive. Staff told us they felt supported by managers and said communication was clear across all levels of the organisation. The provider had contingency plans in place in the event of an emergency, including for evacuation of the home, loss of power, or outbreak management, to ensure people’s safety was maintained.

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. Leaders built strong relationships with external health and social care professionals to make sure people received the right care at the right time.

Staff worked closely with GPs, dieticians, therapists and community nurses, and we saw evidence of joint care planning and timely referrals. Weekly GP rounds supported continuity of healthcare, and hospital transfer packs were prepared so essential information, such as Medication Administration Record charts and Do not attempt cardiopulmonary resuscitation documentation, was shared promptly when people moved between services. Visiting professionals described the home as well organised and praised the communication of staff. One GP told us the home was “very good” and that the team was “a pleasure to work with.”

The provider also maintained links with the local community through activities such as visits from toddler groups, choirs and community events, which people told us they enjoyed. Relatives said this gave the home a welcoming and inclusive atmosphere.

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.

They used feedback from people, relatives, staff and professionals to make changes and drive improvements in care. Leaders encouraged a culture of openness where lessons learned from incidents, safeguarding concerns and complaints were shared with staff to prevent recurrence and embed good practice.

We saw examples where shortfalls identified during the inspection, such as storage of personal items in bedrooms or activity records not always being completed, were addressed promptly. Managers took immediate action, reminded staff of expected practice and monitored improvements. Systems were also in place to identify trends in accidents and incidents, and these were reviewed at team meetings to promote learning.

Staff told us they were encouraged to share ideas and suggestions about how to improve the service and said managers listened to them. Families also said they felt their feedback was valued, and that changes were made as a result. This learning culture helped the provider maintain a safe, supportive and person-centred environment.