Chestnut Lodge

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

At our last assessment we rated this key question Requires Improvement. At this assessment the rating has changed to Inadequate. This meant services were not planned or delivered in ways that met people’s needs.

The service was in breach of legal regulation in relation to promoting person centred care to people.

This service scored 32 (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 make sure people were at the centre of their care and treatment choices and they did not work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

We found that care plans were not always person-centred and did not consistently contain up-to-date information about people’s assessed needs. This meant staff did not always have accurate guidance to support people in line with their individual preferences.

Some people were not receiving care that reflected their personal wishes. For example, one person told us they would like more clothes, another expressed a wish to have more showers, and another requested to be able to go outside more often. These needs and preferences had not been reflected or acted upon in their care planning.

Activities provided were not always tailored to people’s individual interests, backgrounds, or cultural needs. For example, bingo was regularly offered as a group activity, but some people told us they did not enjoy bingo and would have preferred other options. This limited opportunities for meaningful and personally relevant engagement.

People’s end-of-life care needs were not fully considered in relation to the location of bedrooms. For example, 1 person receiving end-of-life care was accommodated on the first floor, making hospital admission difficult and potentially undignified. This arrangement could also have impacted the person’s dignity following death. The service did not demonstrate that bedroom allocation took account of individual needs and preferences at the end of life.

There were significant shortfalls in how the provider understood the diverse health and care needs of people and their local communities, so care was not joined-up, flexible or supportive of choice and continuity.

The provider failed to meet all core service obligations. We found not all nursing care residents were receiving the nursing care they were paying for. People who required regular repositioning and nursing input were not always supported as per their assessed needs. This meant there was a risk of avoidable harm and unmet clinical needs.

On 1 unit, the manager told us that senior care staff were giving medication to people. This practice did not align with safe nursing care delivery where nursing oversight is required.

Joined up working between permanent staff and agency staff supporting people on a 1:1 basis was not clearly recorded. On both days of the assessment, leaders were unable to confirm who was on the rota to provide this support. This lack of clarity created a risk of inconsistent care and reduced accountability.

We saw minimal evidence of people being supported to access the local community or community groups. However, we noted the provider had arranged a summer fayre which was attended by family, friends, and local residents.

Partners told us they did not feel the service was working cohesively with them. This suggested gaps in communication and collaboration between the service and external stakeholders.

The provider did not always supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

The service made some attempts to provide accessible information for people living with dementia. Easy-read menus with pictures were available on the dementia unit, and dementia-friendly signage was displayed around the service. These measures supported some understanding of daily routines and helped people navigate the environment.

However, we were not assured that people consistently had access to the information they needed about their care. We saw no evidence that care plans were routinely provided to people or their representatives, and there was no evidence that information was available in alternative languages for people whose first language was not English. There was no clear process for people to follow to gain access to their electronic care plans, meaning people and their representatives could not easily view, discuss, or understand their care and support arrangements.

The provider did not make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff did not involve people in decisions about their care or tell them what had changed as a result.

The service did not consistently listen to or involve people, their representatives, or staff in shaping care or improving the service. Complaints were not well-handled. There was no clear record of outcomes for complaints submitted via email that we reviewed, and the process and actions taken were unclear. There was an overall tracker to identify who had complained, however, this was not made available during the assessment by the management or leaders in charge of the service as they were unable to locate this. Following feedback this had been provided to the lead inspector however, complaints were not reliably recorded on this. For example, the service’s June 2025 audit showed 1 complaint had been received from a person's family member, but no details were provided regarding the nature of the complaint, whether it was substantiated, or whether any lessons had been learned. When we requested complaints records for the previous 7 months, these were not provided, indicating that there was no centralised process for recording or monitoring complaints. Furthermore, this specific example of a complaint was not captured on the complaints tracker that was provided.

Resident meetings did not result in action. Minutes from 4 March 2025 showed residents expressing interest in outside outings and activities, similar to feedback provided on 14 February 2025, yet no action had been taken. No evidence of relative meetings or surveys was provided, meaning family engagement and input were limited. However, the service did have an electronic feedback system which allowed visitors to score the service on a scale 1-5 stars. 71% provided 5 stars but we were unable to see any specific feedback or who the visitors were that gave this feedback.

Staff told us that meetings did not always provide a safe or supportive space for them to raise concerns or contribute to improvements. We reviewed records of staff meetings, including one held on 27 March 2025, which showed that when staff highlighted challenges such as limited time to read and update care plans or concerns about the length of medicine rounds, their feedback was not constructively addressed. Instead, responses from leaders were often dismissive or critical. In some cases, staff were criticised for not performing correctly, without constructive guidance or support being provided. Staff described these meetings as punitive rather than consultative, and said they felt raising concerns was discouraged and their feedback was not valued.

The provider did not always make sure that people could access the care, support and treatment they needed when they needed it.

People were generally able to access the service safely. Lifts were available to move between units and floors, which reduced the risk of exclusion for people with mobility difficulties. People had access to call bells where required, ensuring they could request support when needed, which promoted their safety and independence. Managers were available remotely when not on site, and during emergencies we saw staff gaining support from additional services. This meant people’s needs could still be met during periods of increased pressure, reducing the risk of delayed or unsafe care.

Some people required staff who spoke a first language other than English. Whilst the service employed staff who spoke Punjabi and other languages, they were not always on the rota to work in the units where people who spoke those languages were living. This meant that people who relied on staff with shared language skills were at risk of reduced involvement in their care, poorer understanding of their treatment, and possible feelings of isolation. The lack of consistent planning for language needs limited equity of access to the service.

There were some positive adaptations. For example, 1 person who was nonverbal had picture cards available in their room for staff to use. This promoted their ability to communicate and reduced the risk of their needs being overlooked. However, this was not part of a systematic approach across the service, meaning the impact was limited to individual situations rather than benefiting all people with communication needs.

The service demonstrated significant gaps in ensuring that people with dementia, people with personal care requests, and people with language barriers had equitable experiences and outcomes.

People living with dementia did not always experience equitable care. Staff lacked the competence to respond effectively to distress or behaviours that challenge. This placed people at risk of emotional and physical harm and meant their experience of care was poorer than those not living with dementia. As a result, people were more likely to feel unsafe, misunderstood, and unsupported in managing their condition.

One person cared for primarily in their bedroom had asked to access outside spaces, use the toilet more independently, and have more frequent showers. Another person had requested additional clothing. These requests reflected people’s personal, social, and emotional expectations of care. However, these needs had not been explored or considered, which limited their autonomy and reduced their quality of life. The failure to respond to such requests increased the risk of people experiencing isolation, neglect of dignity, and dissatisfaction with their care.

People with language barriers were not always provided with the same opportunities to express choice or maintain independence as their peers. For example, one person from a Spanish background struggled with communication, but no alternative methods, such as translation support or visual aids, were documented as being explored. This breakdown in communication restricted their ability to influence their care and increased the risk of inequitable experiences and outcomes compared with others in the service.

People were not supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

We reviewed the care plans of 2 people which had been documented as end-of-life care. However, the registered manager informed us there was only 1 person approaching end of life, and that person was not yet receiving end-of-life care. This inconsistency meant care planning did not accurately reflect people’s needs, placing them at risk of receiving inappropriate or unnecessary care. It also created the risk that their families could be given misleading information about the stage of their loved one’s condition.

The care plans we reviewed lacked detail and specificity. They did not include information about people’s wishes, preferences, or expectations regarding how they wanted to be supported as they approached the end of their life. This left staff without the guidance required to deliver personalised care, increasing the likelihood that people would not have their dignity, comfort, or cultural needs respected. The absence of future planning meant that important choices about treatment and support could be overlooked, which could cause significant emotional distress both for the person and for their relatives.

The lack of meaningful, person-centred end-of-life planning meant people were at risk of experiencing care that was generic, unresponsive, and not aligned with their values. Families could not be assured that their loved ones’ final wishes would be recognised or respected, undermining trust in the service and creating potential harm at a critical stage of life.