Chapel Lodge

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 required 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 good governance.

This service scored 61 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities. The provider’s values were displayed throughout the home, however staff and leaders did not ways work in line with them. For example, people were not always included in decisions about their care, and their independence was not always promoted.

Not all leaders understood 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. The management team were compassionate towards people, relatives and staff although they did not always lead effectively. Some people and relatives we spoke with told us they did not know who the manager was. Leaders had not always supported staff to deliver safe and effective care which met people’s needs and improved their outcomes.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had a whistle blowing policy in place and staff felt supported to raise concerns. Staff told us the management team listened to suggestions and ideas.

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 management team told us they had a diverse workforce and made reasonable adjustments to support staff. Staff had access to a staff handbook which included information about workforce equality.

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 management team did not always have a good overview or insight of the service. Audits in place did not always identify concerns we found during our assessment in relation to safe care and treatment, person centred care, IPC and good governance.For example, the last infection control audit completed at the end of July 2026, scored 90 percent, this was not in line with our findings. Care plan audits had identified some gaps in daily records but had not identified the shortfalls we found in care plans which were often contradictory. This meant a lack of effective oversight may result in concerns not being identified through the quality assurance process, limiting opportunities to implement improvements and enhance service delivery. Following our inspection the provider took appropriate actions to ensure governance in the service improved, however, new systems and approaches required embedding into practice.

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 management team were in the process of responding positively to advice from the local authority and implementing an action plan to strengthen practice and improve outcomes for people. One external professional said, “We offered training to frontline staff, this was discussed with manager in a managers meeting, however the care home unfortunately did not attend this.”

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. At our last inspection the service was rated good, however, the at this inspection the service had deteriorated to requires improvement. Since our last inspection the provider had introduced electronic care planning, however we found gaps in recording and care plans which were not person-centred. Processes were in place to carry out lessons learnt exercises with the intention of improving the service.