Chalfont Lodge

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 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 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.

The service had a positive culture, demonstrated by staff and leaders who were passionate and innovative in ensuring a shared vision and strategy for delivering high quality care.

Staff told us how they enjoyed working at the service. One staff member said, “The manager is fully supportive, I get all the support I need here.” Another staff member said, “I have been here for over 6 months. What I like is that there always seems someone available to talk to. I get all the support I need to do a good job.”

The provider had exceptionally 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 always did so with integrity, openness and honesty.

Staff consistently told us how they felt supported in their roles and how they found the registered manager approachable, open, and honest. Staff told us the communication systems and team working within the service were robust and effective. Staff told us they had briefings and meetings to keep up to date.

People and their relatives spoke with us about the management at the home and were very positive in their comments, which included, “[Registered manager] is always around, that is normal, he is always around, a really nice man”, “[Registered manager] has an open door policy here, his door is always open, you just knock and he attends” and “I do know the manager here, he always speaks to you. Although he is always busy, he still has time for you, his door is always open. I like him a lot.”

Both staff and visiting healthcare professionals told us, “I absolutely love it here, it is a very good home. The management at Chalfont are open, honest and so responsive”, “I believe they [management] seem to be continually striving to improve here. The manager is superb” and “The deputy manager, manager and unit managers will come on the floor to help, we are a very capable team.”

Throughout the inspection the registered manager was open and honest. He was keen to show the service at its best but open to our suggestions and comments. We saw he was warmly greeted by people and staff around the home, and he demonstrated a drive and genuine affection for those he talked too.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Policies were in place to support this culture.

Regular meetings were held with staff, including supervision, handovers, and briefings. Staff told us they felt confident in speaking up to raise issues or concerns.

One staff member said, “I can be very vocal sometimes, yes, I can speak up. It is safe to do so and they [management] do listen.” Another commented, “Speak up champions are also available and we have the whistleblowing telephone number in our staff room.”

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 manager demonstrated how they valued staff by working closely with them to understand staff’s individual needs and by making reasonable adjustments to accommodate and support them in their work.Staff told us where adjustments were made to their working week to support them.

We saw staff came from a range of diverse backgrounds and cultures, and worked well as an integrated team.

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.

Effective systems were in place to monitor and improve the service. These systems flagged concerns such as missed medicines, accidents and incidents.Audits were regularly conducted and action plans to improve the service were in place. The registered manager met regularly with their line manager who provided support working through the action plans. For example, it was identified care plan reviews could be improved. The registered manager identified changes to the process and delegated tasks to unit managers to implement these changes. Staff were briefed and we saw improvements had taken place. Meetings were held with staff following the changes to ensure the improvements were embedded into working practice.

The registered manager had been working closely with the local authority to improve the service. We contacted the local authority for feedback and were told, ‘Chalfont Lodge is a very good service. There is strong leadership and the registered manager and deputy manager work well together. The staff team are stable, and many have worked in the service for several years. The home does not use agency [staff].

The team have worked hard to improve the service and want to showcase what they do well. Clinical governance is strong. The Deputy Manager oversees all clinical compliance. The home has a strong community presence.’

The registered manager told us, “We use our audit process to improve the service and outcomes for people we support. Fortunately, my line manager is very supportive, and we regularly meet to discuss improvements.”

The provider clearly understood and carried out their duty to collaborate and worked in partnership, and services worked seamlessly for people. They always shared information and learning with partners and collaborated for improvement.

The provider had built excellent links with community services and healthcare services such as GPs, physiotherapist, dentist, podiatrist and optician, as needed. Visiting healthcare professional all spoke very highly of the service. The home arranged regular trips out into the local community by minibus to museums, garden centres and other places of interest.

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 service documented learning within incidents and accidents and took direct action to support people and keep them safe. Staff felt they received feedback about incidents in a timely manner.

The home conducted regular surveys to seek people’s and relative's views and opinions to improve the service. The registered manager responded to requests posted in these surveys. For example, one relative requested information in relation to activities in the home. We saw a weekly activities information sheet was emailed to all those families who requested the information. Another request was for more ‘seasonal food’, and the chef had amended the menu to meet this request.