The Chase

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

This service scored 36 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

The service has been performing badly since 2016. We found no evidence the provider had significant oversight of the service or the ability to drive and maintain improvement. The service had a history of not sustaining improvement, so the care people received was not consistently safe or good. We asked the registered manager about the values and goals of the service, they told us, “From my side because of the age of people it will be their last place of residence. We accommodate as much of their wants and wishes. It's like God’s waiting room. For some people we have end of life plans for others not as they don’t like discussing it.” The registered manager did not provide further information about their vison of the service or how they fully engaged the staff team to shape the culture or plan how to improve the care people received.

Leaders did not have the skills, knowledge, experience and credibility to lead effectively. The service had not sustained any significant improvement, and people did not receive safe care and treatment.

Although we have raised concerns and taken enforcement action against this service previously the provider had not implemented a robust system to maintain their own oversight of the quality of the service. We were not assured leaders had the skills to make and sustain the necessary changes at the service. The registered manager demonstrated a lack of knowledge around their responsibilities when we fed concerns back about the management of people’s health needs.

The registered manager was also the provider. They told us a manager from their sister service would come to The Chase to do audits but provided no evidence of this so we were not assured.

People did not always feel they could speak up and that their voice would be heard. Staff provided mixed feedback about the management of the service. There was no process in place which supported improvement in the service through any feedback it received although some staff felt able to raise concerns.

Although daily handovers occurred and the registered manager told us there was a senior WhatsApp group to share information (messaging on phone devices) there was no formal process to collect staff feedback through surveys or questionnaires. The provider had no process in place which created a safe space for staff to speak up anonymously to raise concerns. One staff told us they felt meetings were only called if something had gone wrong and carers were blamed and not listened to. They felt there were no formal opportunities to share feedback such as surveys. When they shared feedback in supervisions concerns were not always acted on or they were dismissed. Another staff member told us they felt everyone worked together well as a team, and management were very supportive if there were any problems or concerns.

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 provider has continued to fail to ensure there was effective oversight to assess, monitor, and improve the quality and safety of the service. Systems and processes had failed to identify and mitigate risks. This has put people at continued risk of not having their needs met.

The registered manager and provider had not identified that care plans and risk assessments lacked important information or were inconsistent. Systems to monitor the service were not effective, for example the issues we found with medicines had not been identified through the audits which had been completed. There was a continued failure at the service to provide consistent safe care to people. A care plan audit conducted in June 2025 only looked at 6 people’s records and did not identify the lack of detail and necessary information staff required to support people safely. Any improvement that had been made previously has not been embedded or sustained. During previous inspections we have found similar concerns and repeated breaches of regulations. Since 2016 we have identified significant concerns around risk management, staffing, dignity and respect, governance, premises and equipment, recruitment, person centred care, consent, managing complaints, and safeguarding.

At this inspection we have found significant concerns in relation to the management of distressed emotions, pressure damage, staff training and competencies, constipation, diabetes management, recruitment of staff, person centred care and the environment. We are concerned there continues to be ineffective oversight of the service with ineffective systems and processes which do not effectively assess, monitor and mitigate risks relating to health and safety and welfare of people. This had put people at significant risk of harm. Staff do not have the information or training required to safely support people.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. There was a lack of understanding around their responsibilities in managing and supporting people’s health needs.

There was a heavy reliance on outside health professionals to manage people’s health needs but a lack of robust and planned process or safe oversight within the service. Records indicated people had not opened their bowels for numerous days which had not been identified by the registered manager or staff or shared urgently with other health care professionals. There was no information about people’s wounds and staff were provided with no information around how they should support people to manage their wounds to prevent further deterioration.

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. They did not actively contribute to safe, effective practice.

There was a complete lack of learning or sustaining any improvement at the service. The registered manager and provider had failed to establish effective oversight of the service. Continued concerns were found in areas we had reported on before and told the provider to improve. The provider had not implemented an adequate improvement systems at the service and continued to lack oversight or leadership.

There had been no learning from when people had been put at risk and exposed to harm previously. We were extremely concerned that the provider continued to fail to address concerns in regard to the recruitment of staff and management of health risks. Any action taken previously to make improvements was not effective or embedded.