Chapel Garth EMI Residential 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.

This service scored 61 (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. Some leaders could not explain what the provider’s values were and therefore were not always part of a shared culture. Some leaders within the service did not always challenge poor practice and did not guide staff in an appropriate way. The senior management team addressed our concerns and were working with the new manager to improve the culture.

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 provider had recently employed a new manager at the service who was in the process of making changes to improve the service. Leaders had not always supported staff to deliver safe and effective care which met people’s needs and improved their outcomes.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The staff team were actively promoted and encouraged to use the whistleblowing policy if they had any concerns in relation to people. This enabled appropriate intervention and input to be provided by the management team. The senior management team told us they were available at all times to support the home.

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 providers equality and diversity statement was on display in the entrance of the home.Staff received training in equality, diversity and inclusion.

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. The management team did not always have a good overview or insight of the service. Audits in place did not always identify concerns we found during our assessment and where issues were known, they had not been resolved in a timely way. For example, the build-up of leaves outside creating a hazard when evacuating from the building, deployment of staff, staff attitudes and approaches and improving the skills of members of the management team. The senior management team carried out audits to ensure the management team were operating governance systems in line with the provider expectations.

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. The home participated in regular contract monitoring visits from the local authority.Staff and leaders had built a good professional relationship with the local authority along with other professionals that visit.The home worked closely with GP’s, social workers and the safeguarding team, who visited the home regularly.

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. Following our site visit the provider sent us an action plan to address the initial concerns we found. Some issues were resolved straight away.