Chorlton Place 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 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 good governance. The provider’s governance systems were not effectively established to ensure compliance. The provider did not always monitor and mitigate risk relating to the health, safety and welfare of people living at the home. Accurate records were not always kept in respect of each person living at the home.

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 aimed to demonstrate a clear vision, strategy, and culture. This was based on transparency, equity, equality, human rights, diversity, inclusion, and meaningful engagement with individuals and their communities.

Improvements since the previous assessment were evident. Staff reported feeling more valued and respected, and the provider maintained an open and honest dialogue about areas still requiring development. Most relatives acknowledged positive changes, noting that the current manager was transparent, approachable, and actively engaged with people, their families, and staff. This inclusive ethos was consistently reflected by the area director, with both leaders fostering a culture of empathy, active listening, and collaboration, an approach that was echoed in feedback from staff and relatives.

Operational policies were easily accessible and provided a clear framework for daily practice within the service. Recruitment processes were values-led, incorporating interviews designed to assess candidates’ alignment with the provider’s ethos and commitment to high-quality, person-centred care.

While there were positive developments in leadership at Chorlton Place Nursing Home, we were not fully assured that all leaders demonstrated the capability required for their roles. Feedback regarding the accessibility of the registered manager was mixed. The registered manager was not present during the assessment.

The assessment was facilitated by the turnaround manager (a manager employed by the provider) and area director. The current manager, who had been in post for several weeks, was described by residents, relatives, and staff as visible, approachable, and committed to transparency. The manager shared an example of an open and honest conversation with a family member, which was corroborated by the relative involved, reflecting a positive shift in leadership culture.

The provider was actively supporting deputy managers, senior staff, and nurses to develop their leadership skills and clarify their roles and responsibilities. Leadership by example was being promoted across the team.

However, further scrutiny was required to ensure robust clinical oversight. We were not assured that the provider had effective systems in place to monitor and uphold the quality and safety of clinical care. Specific concerns included the management of medicines, diabetes care, and the safe use of oxygen therapy. These areas require strengthened oversight to ensure safe and effective clinical outcomes for people.

The provider fostered a positive and open culture in which most staff felt empowered to speak up, confident that their voices would be heard and respected. Work had been undertaken to embed the organisation’s core values into the daily practice of staff, promoting a culture of transparency and respect.

The manager emphasised their commitment to cultivating an environment where staff could raise concerns or share feedback without fear of reprisal. This approach was supported by clear policies and procedures, including a whistleblowing policy.

Staff confirmed they felt comfortable speaking up when necessary and demonstrated awareness of the whistleblowing process.

The provider demonstrated commitment to valuing diversity within its workforce and actively promoted an inclusive and equitable organisational culture. Efforts were made to improve equality and equity across all levels of the service, ensuring that staff felt respected, supported, and empowered in their roles.

Staff reported feeling valued by the current manager and described the workplace culture as fair and inclusive. The provider had implemented initiatives to raise awareness of different cultures, backgrounds, and behaviours, aligning these efforts with the organisation’s core values.

Staff were supported through access to additional training and development opportunities and were actively encouraged to pursue progression into senior roles.

The provider did not consistently demonstrate clear lines of accountability, well-defined roles, or effective governance systems.

Governance processes lacked consistency in identifying areas for improvement, and timely action was not always taken to address known issues. For example, a digital care record audit conducted in May 2025 failed to identify missing information in diabetes care plans, whereas a subsequent audit in June 2025 revealed documentation gaps. This had been identified at the last assessment and not enough improvement had been made. Additionally, governance oversight did not adequately address the safety measures required for the management and use of oxygen for one individual. Recurring concerns were also noted in monthly dining audits, which remained under review at the time of assessment.

Some medication management processes had improved but it was evident systems for medicines oversight were not identifying where people were placed at risk with some people regularly running out of medicines and people were not being safely supported with the safe administration of insulin. This had placed people at risk and the provider had not identified this. Unsafe medication management had been identified at the last assessment and not enough improvement had been made.

Some staff felt they had not been given enough support to understand and use the electronic care planning system and this was evident as there was often a failure to ensure care and treatment was reported in real time and care notes lacked person-centred detail. We found there had been no systemic roll out of the electronic care planning system to ensure digital records were fully reflective of people’s needs.

Despite these challenges, there were examples of proactive leadership practices. Out-of-hours spot checks were conducted by leaders, and staff engaged in daily flash meetings and handovers to support effective communication and continuity of care. The provider had contingency plans in place to manage emergencies such as electrical or heating failures, demonstrating a degree of operational preparedness.

Furthermore, the provider worked collaboratively with local authority monitoring teams to embed and sustain improvements. Feedback from the local authority was positive, indicating progress in some areas.

The provider demonstrated a commitment to partnership working by collaborating with local authorities, health and social care professionals, and hospital discharge teams. This coordinated approach ensured that people received seamless care transitions, particularly during hospital admissions. We observed that when individuals were transferred to hospital, comprehensive and relevant information accompanied them, enabling hospital staff to respond effectively to their needs.

In addition to clinical partnerships, the provider fostered meaningful connections with the wider community. Local schools were invited into the home, promoting intergenerational engagement. The provider also established relationships with advocacy groups, ensuring that residents’ voices were heard and their rights upheld.

The provider had not consistently embedded a culture of continuous learning, innovation, and improvement across the organisation and wider local system.

Although regular audits were in place, they did not always identify areas where improvements were needed, particularly in relation to missing information within care records and the safe management of medicines. We found the provider was not pro-actively identifying where there were discrepancies in medicines management and this had resulted in people missing medicines. Further work was required to ensure that digital care records are used proactively to monitor care delivery and drive better outcomes.

The current manager has taken steps to strengthen oversight by increasing the frequency of out-of-hours spot checks to ensure compliance with care and support standards. The provider remained committed to improving the quality of care within the home and is actively using feedback and reflective practice to enhance outcomes for people using the service.