Chiltern Support and Housing

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 remained requires improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

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

This service scored 62 (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. A member of staff told there was a focus on team effort and, “I’ve seen the company progress since I have come in.”

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. A member of staff told us the director was approachable, accessible and led by example. The provider held staff meetings.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had a freedom to speak up and whistleblowing policy and procedure. A member of staff told us they were aware of freedom to speak up and, “it will be me raising concerns regarding something which I feel is not right or if the care being provided is not adequate, I should voice this openly, suggest alternatives and it shouldn’t be held against me that I said that, bullying, sexual harassment etc.”

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. A member of staff told us staff are treated fairly and get the same training and opportunities regardless of their roles or backgrounds.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Audits were not always effective in identifying issues as they did not identify the concerns CQC identified during this inspection. We found improvements were required in the provider’s records which had not been identified through audits. For example, care records relating to Non-Abusive Psychological and Physical Intervention (NAPPI) being used had not been documented fully and there was unclear recording. The audits failed to identify risk assessments had not been fully completed, for example, in relation to emollient creams being a fire risk nor correct information being recorded within people’s medicine records. The provider did not conduct audits of their recruitment files to ensure safe recruitment. The training records did not always include evidence of specialist training. The audits did not always identify if consent was obtained before delivering care nor if mental capacity assessments and best interest decisions had been completed. We identified there were errors in the medicine counts and the required signatures of staff. The MARs audits did not recognise errors, list action plans nor highlight any discrepancies in the medicine counts. The provider had not established effective systems to enable them to ensure compliance with their legal obligations and the regulations.

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. We received positive feedback from professionals. A professional told us the service understood a person’s needs and this person was support with care, warmth and attention. The professional also told the provider would get in touch with them if they were concerned about the person. Professionals also told us the provider were responsive, approachable, interactions have been positive and pleasant, and they will go “the extra mile for the service users and will support staff at the service during times of crisis or escalated behaviours.” Professionals told us the provider worked well with them to ensure the safety and wellbeing of the person and “liaising with other agencies to ensure care is delivered in a positive and person-centred way.” A professional told us, “Staff have shown resilience to managing very complex cases and this has been key to ensuring service users receive consistent care.”

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. Staff gave us mixed feedback. We were told, on occasion when problems were foreseen and raised, this was not always followed through. However, we were also told meetings were held where everyone can share ideas on how to improve and the service held regular meetings whereby people using the services, their families and staff could share feedback.