Chase Park Neuro Centre

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 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 Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, as there was a failing of good governance at the service.

This service scored 50 (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 a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The registered manager and staff demonstrated a clear understanding of the provider’s core 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 home. The provider and registered manager were responsive to the feedback given during the assessment and took action promptly to address the some of the shortfalls identified in the environment and care plans.

Some members of the leadership team did not fully understand the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. 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 provider and management team demonstrated an understanding of their responsibilities to ensure people received safe and appropriate care. However, some staff expressed concerns about communication within the home and the adequacy of staffing levels. These issues had been raised with the management team, but staff reported that no noticeable improvements had been made.

Staff were supported in their roles and were proud to work at the service. Comments included, “My time here at Chase Park is very rewarding. I work within a very strong therapy team who all get along very well and work fantastic together. I enjoy coming into work each day and know we make a difference to each and every person we see” and “If I ever needed to raise any concerns or safeguarding issues; I find these were dealt with in a timely manner. We have regular staff meetings once a month. If you are unable to attend the meeting, the minutes from the meeting are typed up and placed where you can read and sign, so you are aware of what has been discussed in the staff meeting.”

People did not always feel they could speak up and that their voice would be heard. One person told us, “I don't go to the residents’ meetings now, I used to, but it is a waste of time as no one listens.”

The provider had a clear whistle blowing policy. Staff were provided opportunities to share feedback and knew how to raise concerns; however, they told us they did not always feel comfortable doing so or that the management team would be receptive to feedback. One staff member told us, “I feel that not all suggestions are taken on board. For example, staff have raised concerns about short staffing and its impact on care many times, but little has changed.”

People were given opportunities to express their feelings about the service through meetings and feedback surveys. Relatives confirmed their confidence in the staff team to respond to any concerns raised.

The provider did not always consistently demonstrate a commitment to workplace diversity and did not always engage with staff or create a positive organisational culture.

Staff gave mixed feedback about the support received from the management team. Some staff said they did not always feel they could approach the management team with issues as they were not confident, they would respond appropriately. One staff member told us, “It can be difficult to raise ideas or opinions on decisions that have been made, as these are received negatively as criticism, and causes an uncomfortable working environment.”

Staff told us they were able to ask for reasonable adjustments to be made to their working patterns for specific needs which the management team were happy to support.

The provider did not have clear responsibilities, roles, systems of accountability and goodgovernance. They did not act on the best information about risk, performance and outcomes, orshare this securely with others when appropriate.

We found the provider’s quality assurance systems were ineffective and did not give sufficient oversight to ensure safe, good‑quality care. Although a full suite of audits was in place, they did not consistently identify issues, and when concerns were highlighted, appropriate action was not always taken. At our last assessment, we asked the provider to complete an action plan to address the issues found; however, at this assessment, we saw that the majority of these actions had not been completed and the same concerns remained. Some audits were reduced to tick‑box exercises and did not meaningfully assess or mitigate risks to people.

The provider did not carry out their own independent audits but relied on findings from in‑house checks. This meant they did not identify areas needing follow‑up because they were not reviewing the information firsthand.

The service had a governance dashboard that provided real‑time data on areas such as skin integrity, falls, accidents, weights, infections, medicines, and staff training. However, despite having this information available, the provider did not act on the issues identified, and the audits remained ineffective.

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.

Healthcare professionals provided mixed feedback about their interactions with staff. Some praised the collaborative working, but others were concerned about the partnership which had resulted in a decline to the care delivery. A health and social care professional said, “I do not feel the standard of care is what it was. The person themself initially felt happy in Chase Park and would describe the care as excellent and the staff attentive. They did not want to return home a few months ago, but now things have changed.”

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. They did not always actively contribute to safe, effective practice and research.

The provider's own quality assurance was ineffective and had not identified some of the shortfalls found at this assessment. Some of these were present at the last inspection. However, lessons learned reviews were completed and shared with the staff team to promote improvement across the service.