Chadcome Healthcare Limited

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. This is the first assessment for this service. This key question has been rated 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 breach of legal regulation in relation to 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 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. There was limited clarity on the shared vision of the service. The provider wished to expand the service, however, had insufficient systems in place to monitor their current provisions to promote inclusion and engagement. There was limited formal engagement with the staff team. A staff member said, “With staff meetings, [nominated individual] might do half an hour or so, we have a group chat where we will update if someone needs something. Not exactly a meeting with us in a room but we need to do more when the new carers start working with us.”

Not all leaders understood the context in which the provider delivered care, treatment and support. 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 registered manager did not hold day to day oversight of the service; we were told during the inspection they had moved abroad. The provider had not completed the CQC issued annual Provider Information Return (PIR) for 2025. The nominated individual told us they understood the registered manager had completed the PIR but had not checked this. Statutory notifications and applications to update CQC of management arrangements had not been submitted. The nominated individual told us they had recently identified shortfalls within documentation and had plans to improve record keeping. Dates of the documents we reviewed during the inspection were not always clear, forms completed post 2026 were written on templates dated February 2026, these included recruitment records and spot checks.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Systems were in place to enable staff to speak up. The whistleblowing policy included details of outside agencies staff could approach if required. The nominated individual described good communication between the staff team, often involving informal discussions which could be escalated into formal meetings if required. People and staff provided positive feedback about the management team. Their comments included, “If I had any concerns it would be [nominated individual] I go to, I think they would listen to me. [Nominated individual] is someone who will listen and is very caring and will try to action as best as possible.” And, “I haven't needed to raise any concerns but I have phoned them when staff have been late, this doesn’t happen very often.”

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 valued working at the service. The nominated individual shared plans of regular meetings, supervisions, checks and flexible working hours to consider staff’s personal caring responsibilities, and any protected characteristics.

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. There was a lack of quality assurance processes to ensure people were receiving a high standard of care. There had been no checks to review the standards and completeness of care records leaving people at risk of receiving unsafe support. Systems had not identified missing documentation such as consent forms. People’s feedback was not routinely sought and care reviews were not always documented to ensure their views were captured. Audits of medication administration were ineffective as they had not identified the shortfalls found during the inspection. This meant people were at risk of harm due to medicine concerns not being identified and addressed. The majority of the provider’s policies had not been reviewed and personalised to the service. Policies had not been completed with information, such as, where to escalate safeguarding concerns and who the IPC lead was. The safeguarding children policy abruptly ended midway through. The provider responded to our concerns and advised they will be using new tools and templates to monitor the governance at the service and had plans for a new manager to join them. They further confirmed all policies will be reviewed and completed.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. The provider told us they linked with partners in care where possible, the people they supported independently managed their own appointments; however, care records were updated to reflect when people had attended the opticians or had visited chiropodists etc. Staff gave examples where they had encouraged people to join in events in their local communities, such as, visiting the pub, going for walks and attending yoga sessions.

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. There was a lack of auditing and checks within the service which meant there missed opportunities of learning and improving from the outcomes. The provider told us they attended industry relevant seminars for networking and learning. They said they received training from various organisations and had signed up to receive updates from the local authority, their policy provider and CQC.