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 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 remained in breach of legal regulation in relation to governance at the service.

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 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 new management team were aware of this and were clear and expressive about the values of the home. The new manager had a clear vision of actions and improvement for Chetwynd House, however more time was needed to see these changes and improvement embedded with the home and the effects for people and staff.

Since the last assessment the provider had recruited inclusive leaders at all levels who understood the context in which they delivered care, treatment and support. The manager and care manager acted with integrity, openness and honesty during the assessment, they acknowledged the concerns raised with medicine management and governance and took immediate steps to ensure risk were mitigated and reported appropriately. However, the management team and provider had not identified some of the repeated concerns identified on the previous assessment. Staff told us they were optimistic about the stability and capability of the management team. One staff member said, “They [management] have fitted right in and are part of the team, we feel heard and changes are happening. We have a way to go but now I am confident we will get there.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they were supported by the new management team and were confident to speak up, raise concerns or suggest improvements when needed. Improvements had been made since the last assessment as staff now said their feedback was acted upon. One staff member said, “The management team is very visible around the home, we can speak to them and show them issues as they happen.” Another staff member said, “All managers have an open-door policy and we can go to they any time. They are very supportive and always listen.”

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider had clear responsibilities, roles, systems of accountability however the management team needed time and support to embed into the home to ensure good governance. Audits and monitoring systems in use had not identified ongoing concerns we had found with medicines which meant people were at ongoing risk of harm not receiving their medicines appropriately. However, the management team had made improvements to people‘s safety through care planning reviews and update. Additionally, they had improved external stakeholder relationships, such as the local GP surgery. This meant the manager and staff were able to seek support and guidance to enable them to develop and implement improvements in relation to medicine management and governance going forward.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Despite the provider recruiting a new management team and improvements being made in some areas, risks to people’s safety remained - as evidenced within the report. We could not be assured the provider always focused on continuous learning, innovation and improvement across the organisation due to the staff feedback we received.

The provider and management team provided assurance and took immediate steps to ensure learning and improvement were communicated going forward. The new manager had arranged staff meetings with individual teams to ensure staff received effective and consistent communication. The manager said, “Setting up frequent and routine meetings with staff will promote improvement and feedback, staff need to feel supported after management changes and time and consistency will be vital to this.”