Chetwynd House

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 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 provider was in breach of regulation in relation to good governance.

This service scored 54 (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. However, the lack of consistent management with Chetwynd House had meant this was not fully embedded into the culture of the home. The staff we spoke with were knowledgeable about the vision and values of the provider and worked hard to deliver them but staff were not consistently support to deliver these values and lacked support at times when they felt these values were not being met.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. The provider did not have permanent leaders in place with the skills, knowledge and experience to lead effectively. The provider was open and transparent about the challenges they experience recently involving changes in the management of the home and had an action plan in place to address these concerns. However, all the staff we spoke with told us these periods of absence and inconsistency had impacted their ability to support people. One staff member said, “Each new manager had a different way of doing things, we would just get use to a process, and it would change. Standards slip when we [staff] don’t know what’s expected of us.” Another staff member said, “The lack of management has meant teamwork has become even more important and made the staff team stronger, but the lack of leadership always has an impact, we are desperate for stability.”

The provider fostered a positive culture where people felt they could speak up, however because of the management changes staff told us their voices were not always heard. One staff member said, “The senior management are very approachable, but they are not on the floor everyday experiencing the challenges, we raised issues with the last manager, but nothing happened.” Another staff member said, “It’s hard when you go through your concerns and idea with a manager and they leave, but when it keeps happening you start to stop raising issues.”

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. Staff told us the senior management team were approachable and supportive with their needs. One staff member said, “They [senior management team] will always try and accommodate requests for things like childcare issues or personal appointments. I do feel they value our welfare and are supportive where they can be.”

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. We reviewed quality monitoring documents such as audits which the provider had in place. At times these were not always effective. For example, medicine audits and IPC audits had failed to identify the concerns identified within this report, and advice and guidance from other professionals such as the local authority had not been fully implemented. The provider was open and transparent about this area of concern and welcomed the feedback to allow and support them to develop and implement these systems to ensure methods were robust in identifying issues in the future.

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. People and their relatives told us they felt staff knew them well and responded to request for additional support such as GP’s, opticians and chiropodists. A professional we spoke with told us, “Staff are knowledgeable about people, and help as much as they can. They are quick to identify concerns and seek appropriate help.”

The provider did not always focus on continuous learning, innovation and improvement and encourage creative ways of delivering equality of experience, outcome and quality of life for people. The provider and management team missed multiple opportunities to identify and learn from incidents and concerns due to the lack of consistent oversight and quality monitoring. At times, the provider acknowledged that electronic monitoring processes and software issues had impeded this further. Where staff had raised issues and recorded concerns these had not always been acted upon, and improvements had not been identified or acted up upon appropriately.

However, as staff were supported with an extensive training package and had an in-depth knowledge of people needs and wishes they were able to keep people safe despite the lack of effective governance processes.