Chester House Care Home

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 good. At this assessment the rating has changed to 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 provider was in breach of the legal regulation in relation to good governance.

This service scored 54 (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 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 home provides specialist dementia care, and we spoke with the management about how the home provided this care specifically for people with dementia and other cognitive impairments. There were no dementia-specific activities and the home’s décor, and layout did not contribute to helping people live well with their dementia. An unkempt garden with broken furniture meant there was no provision of safe and stimulating outside space to enhance the wellbeing of people with dementia.

The management team told us they support people with their mental health needs, including addiction and depression. However, the service does not have the service specialism to provide care and support to people with a primary mental health need and addictions and staff had not received training in those conditions.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

The management arrangements for presence at the home were unclear. We were informed there was consistent management visibility providing oversight of operations at the home. However, staff and people did not confirm these arrangements. Despite the registered manager holding their post for several years, people we spoke with were mostly unsure of who the manager was and gave us different names of who they thought the manager was. One person told us, "They have had a few managers? I can't think of this one’s name.” Another person told us, “[Name] is the manager. She is at the other home. I don't know if she is easy to talk to."

The management responded to issues raised during the inspection. However, these actions were reactive rather than proactively identified through effective governance systems. The management told us they wished to improve the service; however, concerns found during the inspection had not been highlighted or addressed prior to CQC visiting. Concerns were found across multiple areas, including individual risks, environmental risks, medication concerns, person-centred care delivery and monitoring systems. This meant leaders were not always able to ensure the consistent delivery of high-quality care.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us the management was approachable, and they felt confident to raise any concerns and felt that action would be taken to resolve concerns. Staff told us they would contact CQC if they ever needed to blow the whistle on practice. Where incidents had occurred at the home, we did not see where the management had apologised and provided information about actions taken to prevent the same happening again.

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.

Staff told us they felt supported in their role and raised no concerns about their employment or the management. The management told us staff completed equality, diversity and inclusion training and the provider employed and supported a diverse workforce.

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.

Management oversight of the home was inadequate. We were provided with quality audits and walkaround records of the home. These had been mostly completed by senior care staff and consisted of a tick box exercise. However, they had not identified and actioned the concerns we found on our site visits. For example, infection control concerns, environmental safety, malodours, unclean areas, management of people’s distress and personal care. We were not assured the home was safe, for example, despite being told actions from the 2024 FRA were all completed we did not receive evidence to demonstrate their completion. Oversight required significant improvement to ensure people were receiving safe and effective care whilst always being treated with dignity and respect. Not all information we requested was readily available during the period of the 3 site visits and we had to wait for periods of time to receive the requested information; some of the information was not received at all.

The provider’s Statement of Purpose (SoP) was not reflective of the service they were providing at Chester House. A SoP is a legal document that sets out the details and particulars of the service. The home is registered with CQC with 2 service specialisms; these are dementia and people over the age of 65 years. However, at the time of the inspection, we found the service was supporting people under the age of 65 years with other primary care needs.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The management told us they had established links with some external professionals and community organisations; however, these were not always used effectively to support positive outcomes for people. Opportunities for people to access regular community activities and participate in local events were limited and we saw no evidence of a proactive approach to developing regular and wider community partnerships. The management told us of their plans to develop physical activity at the home for older people. This was not currently in place and therefore, we will review this at our next inspection.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

We saw that relatives’ meetings and resident meetings had been held and feedback gathered from people about their care. However, we did not see evidence of where this feedback had led to significant improvements to people’s quality of care. For example, activities were discussed and people fed back what they would like to do; however, there was no activity co-ordinator in place, no activities programme and people told us there were no regular activities at the home.

During our first day of site visits, we found several people were smokers and one person had daily use of skin emollients. There is published guidance for providers around the significant fire risks to people who smoke and use emollients; however, the management were unaware of these risks, and no risk assessments were in place. As a result of raising our concerns with the management, immediate mitigation of these risks was implemented. Other concerns we raised during our site visits led to a lessons learnt exercise being carried out by the management and this document was shared with us. However, there were no effective systems in place at the time of our inspection to support continuous learning and improvement at the home. Governance records showed audits and checks had not been completed effectively, incidents and accidents were not being analysed for trends, and lessons learned were not always demonstrated through service-wide improvement activity.

Due to inconsistent governance of the service and poor oversight, opportunities to identify trends, learn from events and make improvements to the quality and safety of care were missed. We saw that a lessons learnt exercise had been carried out only after concerns were raised during our site visits.