Chatterwood Nursing 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 requires improvement. At this assessment, the rating has remained requires improvement. This meant there were some shortfalls in governance and oversight.

The provider was in breach of legal regulations in relation to governance at the service.

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.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Leadership of the service had not always been consistent, and leaders had not always had the skills, knowledge, experience, and credibility to lead effectively.

Since 2021 there had been 4 registered managers for the service. The last registered manager left in November 2025. The provider was aware of the impact of these changes on the staff team. Leaders told us previous issues with leadership had negatively impacted staff morale, confidence and consistency of practice. Staff said, management was good now, but they had needed change. The provider had appointed an interim manager from within their organisation, to work with the existing management team in November 2025, whilst appointing a new registered manager, and this process was almost complete. It will take further time for the provider to be able to demonstrate the service has achieved consistency of leadership for people and staff.

In addition to the manager, there was also a clinically trained deputy manager and a clinical lead. Staff told us they felt reassured and supported by the interim management arrangements. A staff member described, “A good working environment with accessible and visible management.” The management team were supported in their role by the nominated individual and were knowledgeable about the priorities for the service.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider did not have effective systems of accountability and good governance. They did not act on all information about risk, performance and outcomes.

The provider’s governance systems and processes had failed to identify the issues we found in relation to, the management of people’s clinical risks, the lack of daily monitoring of the fridge temperature, staff’s failure to act when the fridge temperature was not within the required range or staff’s failure to seek the pharmacist’s guidance when medicines were mixed with food. Processes had not been effective in identifying CQC notifications had been missed in relation to safeguarding’s or the death of 1 person. Although the provider was addressing the issue with staff’s completion of people’s daily records, it was still outstanding following our last inspection.

Following the inspection the provider has informed us of the actions they are taking to address the issues we identified. They now also had a range of audit processes and action plans, which had identified other short falls and supported improvements. The provider received weekly reports on different areas, and the nominated individual completed a 3 monthly audit. Staff were being given responsibility for different audits, to enable them to take more accountability for their work.

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.

Staff worked closely with a wide range of specialist health and social care services, to ensure people’s care needs were met and they received joined up care. A health care professional told us improvements had been made and staff communicated well and acted upon their recommendations.

The provider had good community links which enabled people to access a range of local groups. In addition, they worked in partnership with another local home, where people went monthly to enjoy entertainment with people from the other home.

The provider focused on learning and improvement across the organisation, but systems were not always sufficiently effective to support them.

We found shortfalls during the inspection which we have highlighted in our report. Although the provider was motivated to learn and improve the service for people, their overall ambition was impacted by the lack of fully effective risk and quality monitoring systems. This meant they were not always aware of shortfalls to enable prompt improvement and learning. The provider was responsive during our inspection.

However, the provider was committed to learning which we saw took place both in relation to incidents within the home and from incidents which occurred within their other homes. The nominated individual told us how action had been taken following incidents to ensure all aspects of the environment were safe for people and staff had completed additional training, as outcomes from organisational learning.

The nominated individual told us how the home had been used to trial their new pre-admission assessment before circulation to their other nursing homes. The deputy manager had identified a trend in relation to people’s continence care and was implementing an audit to ensure people had the correct products for their needs. Staff participated in identifying learning opportunities and testing solutions.