Chapter House Care Home

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• 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 newly registered 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 57 (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 had values and a vision in place, but these were not consistently promoted or embedded in practice. They did not always demonstrate a clear shared strategy or culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

The provider had not involved or communicated with people or their relatives in line with their values.

Systems and processes were in place to ensure staff were well supported and equipped with the skills and knowledge to promote a positive culture within the service.

Not all leaders understood the context in which the provider delivered care, treatment and support.

People expressed that they were not always happy with the changes made by the management team. One person told us, "The service has declined since the new management took over." Another person told us, "There has been a considerable number of staff leave since new company came in, I don’t know why but unsettling for us."

Some relatives reported that the manager had not yet formally introduced themselves to them or their family members. The manager explained a meeting had been arranged for all relatives. However, communication with relatives was provided the evening before the meeting, which some relatives felt did not allow adequate time to attend. One relative told us, "The management team don't fully engage with people or their families."

Some staff also noted they had not formally met the manager, though they indicated that early changes within the service were beginning to support improvements in practice.

The manager had recently joined the service and demonstrated appropriate knowledge for the role. The manager was still within their induction period and received consistent support from the provider. Senior leaders attended the service regularly to offer oversight, guidance and assurance during this transition period.

People did not always feel they could speak up and that their voice would be heard.

Systems and processes were in place to provide opportunities for staff people and their relatives to provide feedback to the service. However, some people were unsure whether their concerns would be valued or acted upon, meaning they did not always feel confident that their voice would truly be heard.

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 provider promoted inclusivity and encouraged a positive working environment. Regular meetings were arranged to enable staff to share ideas and raise any concerns, however staff did not always attend these.

Staff achievements were celebrated through awards, and team members told us management often expressed gratitude for their contributions.

The provider’s systems for oversight and accountability were not always fully effective, and some processes did not consistently support safe or well-coordinated care.

Care plans did not always contain sufficient detail about risks to people. Several records reviewed showed missing or incomplete risk information, meaning important details about peoples identified risks were not consistently documented.

The provider did not effectively communicate changes within the service. Changes to staffing deployment, procedures, or expectations were not consistently shared with staff, people using the service, or their relatives.

Some people felt their preferences were not valued by the management team. People reported when they expressed their wishes or preferences about their care, these were not always acknowledged or acted upon.

People and relatives reported they were not consulted or asked for their views when decisions or alterations made that affected the care provided.

The service was going through a period of transition. Although the management team expressed improvements were being introduced to strengthen oversight and care delivery, these changes were still at an early stage. As a result, they were not yet embedded, and people had not fully experienced the benefits.

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 management team and staff were open and honest throughout the assessment. The service worked with external professionals when required and records reflected professional advice given and actions taken to promote partnership working.

During our site visit we noted a variety of health professionals visiting the service to support people with their care needs.

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.

The manager had only been in post for 4 weeks and had started to make some early changes to staffing in the hope of improving outcomes for people. However, these changes were not communicated clearly, which meant that both people using the service and staff were unsure and lacked confidence in what was happening.