Archived: 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 Inadequate. At this assessment the rating has remained 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 legal regulation in relation to good governance.

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.

We continued to identify a closed culture at The Chase (A closed culture is a poor culture that can lead to harm, including human rights breaches and abuse):There was not a clear culture that promoted people’s quality of life, or have person centred outcomes from their care. Elements of instutionalised practice were identified at the inspection, including people regularly being awoken early for personal care and going long periods before being offered nutrition or hydration. Safeguarding and safety events were not consistently identified or reported, and unsafe care practices such as around medications went unchallenged.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively.

Leaders were not consistently knowledgeable about their requirements to provide care in a way that was effective, equitable or effective. They did not acknowledge that certain practices in place were unsafe or impacted people’s quality of life, or seek to proactively identify and improve these. For example they were not aware of their responsibilities to competency assess staff to ensure they were able to administer medications safely, and the risks to people of not undertaking these. The rear garden continued to be out of access and in a poor condition which deprived people of meaningful access to green space, which we also identified at the last inspection and had not been recognised as disrespectful. They had not taken appropriate action to ensure people lived in a service that was hygienic, and did not place them in deeply undignified situations.

People felt able to raise concerns, however this had not ensured people received care that met their needs.

Staff told us they felt comfortable in speaking up and that any concerns would be investigated. However despite this we found that people were placed in unsafe and undignified situations that had not been identified or resolved, and these issues were not being proactively raised by staff. Staff could not always identify who they would raise concerns to, to ensure appropriate timely action would be taken to protect people from harm.

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 treated with equality, and that any adaptions needed to their working patterns in line with personal circumstances were made to support them. One staff member told us “I like to work here. I don’t feel anything negative. I enjoy supporting the people. Management are trying to provide additional support to staff. I can seek advice from the manager who is available at any time, even at night.”. Another staff member told us that changes had been made to their role to align with the personal circumstances, and they had greater enjoyment from work.

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.

Governance systems at the service were not robust, and had not consistently identified or mitigated risks or concerns that were found at the inspection. Although policies were in place to govern safe practice such as around medication management or for administering controlled drugs, these were not being appropriately followed in practice which had not been identified. Checks and audits were taking place such as to monitor the safety of the environment and care documentation, however hazards and risks to people remained present.

The provider’s governance systems remained inadequate and failed to recognise a range of shortfalls in people’s care and the service. This included the lack of monitoring of people’s health and welfare as identified in this report. Leaders had failed to robustly address a poor culture and as a result this placed people at risk. The provider was still unable to provide evidence of an effective system to assess, monitor and improve the quality and safety of the services provided and to ensure they had met the regulatory requirements.

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.

Although we saw some positive examples of the service working in partnership with other organisations, we saw other examples where the service had not followed appropriate professional guidance or reported safety events. For example people were not always being weighed as often as their assessed needs, to allow the service to appropriately monitor and escalate for support where people were at risk of malnutrition. Although people were reaching target fluid amounts set by professionals, we saw significant periods of time where no drinks were being offered so there was a concern that these targets were based on low fluid intake. There we could not be assured that health care professionals who had set these targets had been provided with accurate information.

However we received some positive feedback from professionals regarding how the service worked with them. One stakeholder told us “They always reach out to me, we have a fluid relationship. Senior staff are good and happy to professionally challenge me”.

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.

Learning systems at the service continued to be ineffective. Although some improvements had been made since the last inspection, we identified continuing and new areas of concerns. Where areas needing improvement such as the environment and infection had been identified, they had not been resolved which presented a continued risk to people. Learning was being taken inconsistently from incidents, with actions not continually embedded in practice to improve people’s outcomes. There was no detailed analysis of people’s distressed behaviours to understand people’s triggers and to determine that staff were following the guidance on how best to support people.

The provider remains in breach of legal regulations and had not sufficiently improved from the previous inspection.