Charlton Court Nursing Home

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 remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (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 manager had an open-door policy and told us that although they had not been in post long, they felt a real warmth within the home and that staff were warm caring and wanted to do the best for people. Staff told us that they felt supported by the manager. A staff member told us, “There has been a lot of changes to the structure of Charlton court i.e. new manager, nurses doing paperwork and not in the numbers and having no deputy manager, we are still in the working together process and getting to know how each one of us works.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience, and credibility to lead effectively. They did so with integrity, openness, and honesty.

The new manager confirmed they had applied to register with CQC. A whole-home approach continuing to make improvements to the home was adopted by staff and management. with the manager actively involving nurses and heads of departments in driving positive change. This inclusive leadership style promoted shared ownership of improvements and contributed to a more organised approach. Senior operations staff also visited the service regularly to support the manager and staff.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us they felt confident in speaking up. A staff member told us, “I feel confident to speak up and that my voice would be heard, another staff member said “I do voice any concerns I have, to the manager. Communication needs strengthening outside the care and nursing team. At present the job is challenging with the one nurse on shift and having residents with different needs across 2 floors but hope in time this all gets easier.”

The manager told us, “I created an open-door policy and created spaces for conversation. I suggested things to staff and followed up what staff asked.”

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 service promoted equality and inclusion within the workforce. Policies were in place to support flexible working and provide reasonable adjustments for staff with disabilities or caregiving responsibilities.

Staff told us they felt valued and supported. A staff member told us, “I do feel supported, the manager is approachable and fair,” another said, “I feel well supported at work and feel valued as a person.”

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment, and support. They acted on the best information about risk, performance, and outcomes, and shared this securely with others when appropriate.

Regular audits and checks were undertaken at the service to ensure a good quality of care. The management team understood their responsibilities to raise concerns, record safety incidents and concerns, and report these internally and externally as necessary.

The manager told us “I have an action plan in place, and I am working my way through this. I feel positive that we can continue to make the changes required, I am aware that we need to work out a way to be able to do more activities, unfortunately I do not have a budget to increase the activity role, however I am looking at how we can improve in this area by thinking about different ways to offer and undertake activities.

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 service demonstrates strong partnership working with external professionals and agencies. Staff reported regular involvement from the GP, dietician, speech and language teams, tissue visibility nurses and occupational therapists.

Staff described effective communication and joint working with the local authority. Notifications were sent to CQC as appropriate. A professional said, “the manager and staff seek assistance from external agencies as required. A relative told us “The staff are good at getting in contact if his mum has any health issues or needs anything.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome, and quality of life for people. They actively contributed to safe, effective practice and research.

Staff told us their learning was encouraged and supported. Supervisions were used to reinforce best practice and share lessons learned. One staff member stated “I do know [people] and their needs, but this could be better with more time. Handover period is used to talk about new admissions and changes in needs to our residents.”

The manager had an open-door culture where staff were empowered to contribute ideas and raise concerns. Staff from all departments, including maintenance, activities, catering and housekeeping, were now involved in quality improvement planning, reflecting a whole-home approach to innovation and service development.