Chalkwell Grange

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 continued breach of legal regulation in relation to good governance at the service.

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 service 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. Although the management recognised improvements were needed, governance and leadership arrangements were not sufficiently robust. This meant that day-to-day monitoring and assessment were not as effective as they should have been, creating a risk that the service might not always be safe or consistently meet people’s needs.The completed audits did not identify the concerns we found during this inspection.

Not all leaders understood the context in which the service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation.

There was a clear staffing structure in place with a registered manager, deputy manager and care team leaders managing the day to day running of the service. The registered manager had recently appointed a new deputy manager and team of care leaders to enable more effective allocation of roles and responsibilities.

Most people and relatives told us the registered manager and as managing the service well. A relative told us, “The manager has an open door policy, they are always happy to sit down and talk. They are very proactive.” However, a relative told us, “My perception is that people in management and senior leadership change at short notice. I wonder why people don’t stay very long. The turnover is in line with what is expected but too rapid for me.”

We received feedback from a health professional. They told us, “I feel the service has greatly improved in recent months since having a permanent manger.They have previously had a high staff turnover of manager's and especially deputy managers which has obviously caused a lot of disruption to the home and care staff.”

The management acknowledged changes were required to make improvements to their service.

The service had policy and processes for staff to follow on ‘whistle blowing’. The registered manager had developed a listening culture where staff felt they were available for them to talk to. This meant staff felt supported, valued and confident to raise concerns or seek guidance, which contributed to a positive working environment.

Staff told us they had regular supervisions. A staff member told us “The manager carries out regular supervision. I would have no problem talking to the manager if I had to discuss something with them. They are very approachable, and I can talk to them about anything.”

However, we found incomplete supervision records on staff files and supervisions did not include meaningful reflection or evidence of discussions about staff performance and development. Following the inspection, management told us, they are implementing a new staff supervision form to ensure a consistent and structured approach to monitoring staff performance and professional development.

There was a policy in place to protect staff from harassment and bullying and a focus on protected characteristics under the Equality Act.

The registered manager had developed an inclusive workforce and recognised the value of diversity amongst the team.

The quality assurance and governance arrangements in place were not always effective in identifying shortfalls at the service. The audits carried out by the registered and deputy manager did not identify the inconsistencies we found. This meant effective auditing arrangements were not in place to assess, monitor and improve the quality and safety of the service provided. Although there was systems in place to ensure staff recruitment files and inductions were audited, these were ineffective to ensure staff files were in line with regulatory requirements. On the day of our visit, the registered manager was unable to evidence a formal record for how they learnt from lessons following incidents. Monthly compliance reports completed by the commissioning manager had not been signed or dated to confirm whether the findings and action plan had been discussed with the registered manager. This meant we could not be assured they had been read or reviewed or acted upon.

Staff meeting minutes did not include detailed action plans completed to evidence how issues raised were to be addressed, dates to be achieved and if actions had been resolved or remained outstanding. The registered manager did not ensure effective monitoring or management oversight of the service.

The service 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. The management had developed good links and worked closely with health professionals. Staff were aware of the importance of working alongside other agencies to meet people's needs and liaised with other healthcare professionals such as the GP and pharmacy when required. The registered manager told us they had recently changed pharmacies to one closer to the service to ensure prescriptions are processed more efficiently and delays are minimised.

The service 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.

The management understood improvements were needed and encouraged staff to discuss and share ideas for improvement and innovation. The registered manager was passionate about making improvements in the service and told us, “I want to keep staff involved throughout this process. There has been a lot of changes here and the staff know I have an open door policy at all times, and I am here to support them. I have a really good team in place now and we are all working well together.”

The staff training matrix had not been updated which meant the service could not be assured that staff had received the required training to carry out their roles safely. The training matrix included outdated information regarding a senior member of staff’s work status which meant the service could not rely on the accuracy of the training matrix.

The organisation was aware they had more work to do to ensure all processes were communicated clearly and embedded to support learning and innovation.