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 inspection we rated this key question requires improvement. At this inspection the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

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

This service scored 32 (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 vision that was shared within the whole staff team, strategy and a culture within the service which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. The provider gave little direction to the team on building a positive culture with collaboration and co-production. Action plans lacked the involvement of staff and people who used the service and their families. The management and staff team were not always working together effectively to ensure a change in culture could be embedded. A staff member told us, “We were told about the last CQC inspection and that improvements were needed but we were not told any more than that.”

The manager did not always understand how to manage and provide care and support. We have highlighted in this report where we identified that the manager lacked oversight of key areas including risk medicines, staffing mental and governance.

There was no evidence that shared values had been developed, agreed, or embedded with staff to promote engagement, ownership, or a consistent culture across the service. As a result, the provider was not meeting its own aims and ambitions as set out in the company’s Statement of Purpose. While the Statement of Purpose described a commitment to person centred, compassionate, and holistic care that values dignity, individuality, wellbeing, and partnership working, this was not consistently reflected in practice. Inconsistent leadership, limited staff involvement, and ineffective governance meant these values had not been translated into day to day care delivery. This demonstrated a failure by the provider to deliver on the standards and commitments they had set for people using the service.
 

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

Leadership at the service had not been consistent as there had been a number of staff changes. At the time of the inspection there was no registered manager in place and there had not been since November 2025. A member of staff told us they lacked clear direction from management and felt that concerns they raised were not consistently addressed. This did not provide assurance that the management team were always effective in leading the service or operating it in a way that ensured compliance with regulatory requirements.

There was a disconnect between the provider corporate team and day-to-day management practice and care delivery. Senior leaders were supporting the manager and staffing team. However, this support was not effective as they did not monitor that the service was not making the necessary improvements within the appropriate timescales or to amend their improvement plans if required for the quality of the service to improve. The provider lacked responsiveness increasing the risk of delaying improvements to the quality and safety of care delivered to people using the service.

We received feedback from a health professional. They told us, “While I am aware there is a new manager who appears approachable, the office door is often closed and the frequent changes in deputy manager have made continuity difficult. Overall, I feel the service is not being managed effectively. The high turnover of staff has left the home feeling unsettled, morale appears low, and there seems to be a lack of consistent leadership and support from the management including the owner.”

During the inspection, we raised our urgent concerns with the provider about governance of the service, who provided assurances and immediately arranged extensive support. The nominated individual has put a new service improvement plan in place to demonstrate ongoing improvement works. Following the inspection, the nominated individual told us a new manager had been appointed to manage the service. There was a support manager, director of care and deputy manager supporting the manager at the service.
 

Staff did not always feel they could speak up and that their voice would be heard. Some staff shared with us they did not feel listened to when they raised concerns. Staff told us issues they raised were not addressed and were dismissed by management. Staff shared concerns that they were worried about repercussions if they reported concerns to the inspection team. This meant we were not assured the service fostered a positive culture where staff felt comfortable and supported to speak up and have their concerns addressed safely. Staff did not receive regular supervision and told us they were not given the opportunity to share their concerns with management.

Most people and relatives told us they had not received a survey to provide feedback. The manager told us they had recently sent one out however had not received any responses. A relatives meeting took place in March 2026 however, the minutes did not include an action plan. A staff survey had been completed in December 2025 and staff had raised concerns. Although an informal meeting took place to discuss the survey results, the minutes from the meeting did not show which survey issues were discussed, lacked clear records of attendance or staff feedback, and contained only broad positive statements with no specific or accountable actions. There were no follow up decisions or dates included for when actions should be addressed.
 

The provider did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them. Some staff felt they were not treated fairly and equitable at the service. Some staff shared with us they felt their roles and responsibilities were not fairly recognised by the provider and there was limited opportunity for development. Lack of recognition for roles had a negative impact on staff and their motivation to work at the service and their overall performance. We could not be assured the provider was engaging with staff equitably.

The provider did not have clear roles, responsibilities, systems of accountability, or effective governance arrangements in place. They did not consistently act on accurate and up to date information about risks, performance, and outcomes, nor did they always share this information appropriately to support safe and effective care.

At our previous inspection, the service’s quality assurance processes had failed to identify concerns or drive the necessary improvements. At this inspection, we found these governance concerns remained. Although some work had been undertaken, including the introduction of new audits to monitor and review people’s care documentation, these audits had not been completed or used effectively to improve the quality of the service. Following the inspection, the manager completed care plan audits which identified shortfalls in care plans and risk assessments; however, no action plans were in place to address the issues identified.

Governance processes were not effective in providing oversight of the service. Whilst the provider submitted an action plan outlining improvements made, systems to ensure compliance with legislation and internal governance arrangements were not comprehensive. We saw the manager was using a variety of different recording tools, which did not support effective identification, analysis, or learning from risks, outcomes, and incidents. Quality audits were not sufficiently detailed or up to date to provide assurance that risks were being well managed or that improvements were embedded.

As a result, people were not always receiving the standard of care and support they should expect. Legal and regulatory requirements were not consistently met, including failures to submit statutory notifications to the CQC in a timely manner for events such as safeguarding concerns or serious injuries.
We also received feedback from a health professional who told us, “The manager lacks insight into the needs of the residents and appropriate staffing. There is also a high turnover of management, which has affected consistent oversight of the service.”

Overall, we found there was a continued lack of effective governance and oversight by the management team and provider. Systems were not robust enough to assess risks, monitor the quality of the service, or drive sustained improvement to positively impact people’s lives and outcomes.
 

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.

We received variable feedback from partners. Most of the feedback we received was not positive. In particular, partners raised concerns communication needed to be improved, both within the staff team and management. Some concerns about documentation were also raised. Feedback on how well staff knew people during partners visits to the service was mixed. Some partners said staff knew people well others said staff did not always know people’s needs.

Feedback from local partner agencies demonstrated concerns regarding the integrity and overall competency of the management and raised questions about the reliability of governance processes that underpin effective partnership working.

However, we also received some positive feedback. A health professional told us, “Communication between me, staff and management has generally been good during my visits. Staff are approachable and engage well, and I have found the management team to be open and easy to speak with”.
 

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. We inspected the service in August 2023 and rated it requires improvement. At the last inspection in January 2026, the service remained requires improvement. The provider had failed to learn lessons and sustain improvement. We found the service was once again in breach of regulations.

Due to the failings identified at this and the last assessment, leaders were still reactively responding to concerns raised by us and external stakeholders rather than being proactive in the development of the service. Whilst improvement work had started, leaders were not yet in a position to demonstrate the longer-term outcomes and benefits for people and staff.

Despite the provider sending us their action plan following our last inspection telling us how they planned to address the shortfalls, we found they had failed to make the required improvements.

Following this inspection, the nominated individual acknowledged the concerns identified on this inspection and confirmed their ongoing commitment to drive rapid improvement across the service, and to reflecting on lessons learned in relation to the outcome of this assessment.