Chestnut 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 Inadequate. At this assessment the rating has remained Inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to good governance at the service, and failure to notify the Care Quality Commission of notifiable safety events, under the registration’s regulation.

This service scored 29 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

Staff within the service did not demonstrate a clear understanding of the provider’s values or the direction set out in the statement of purpose. When asked, staff were unable to describe what the service’s vision was or how it should guide their practice. This meant there was no shared direction, and staff were not working together towards common goals of providing person-centred, safe, and compassionate care.

We identified a closed culture within the service. Staff did not consistently share information with one another and failed to record care accurately. For example, people’s behaviours and moods were not reliably documented, and records of their care were sometimes inaccurate despite staff being aware of their actual needs. This culture of poor communication and inaccurate recording reduced transparency and accountability, limiting opportunities for improvement and increasing the risk of harm.

The impact of this was significant. We were not assured that the care people received reflected the provider’s values or people’s needs and preferences. The absence of a shared culture and direction meant staff worked in isolation, care was inconsistent, and opportunities to promote people’s dignity, wellbeing, and safety were missed. This lack of a clear and embedded vision contributed to poor practice, unsafe recording, and a culture that did not prioritise openness or the delivery of high-quality care.

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. Leaders did not have the skills, knowledge, and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

We found when things went wrong, leaders did not communicate openly or effectively. For example, an allegation of theft had been reported by relatives to The Commission and was alleged to have been reported to management at the time of the occurrences. However, this was not shared beyond management and was not recorded anywhere within the service’s documents. When asked for evidence of how the complaint and investigation into this was handled, the 2 leaders in charge were unaware of this case. This lack of oversight meant not all safeguarding concerns were tracked or monitored, placing people at risk because there was no assurance that lessons were learned or that people were protected from harm.

We found overall complaints were not recorded properly, which meant leaders were unaware of certain concerns raised by people or their families. As a result, issues were not investigated in a timely or consistent way, and people could not be assured their voices were heard or acted upon.

The manager had failed to ensure that notifiable safety events were reported to the Commission as required. When we randomly sampled the safeguarding log, we found the 4 incidents we reviewed which were recorded between February and July 2025 had not been reported to CQC. This demonstrated a lack of effective oversight and governance in ensuring statutory reporting duties were met.

The registered manager and deputy failed to deploy their management duties effectively, which allowed a culture of poor reporting and inaccurate recording to continue between assessments. This placed people at further risk as unsafe practices persisted without correction. Staff were not supported to change, and people’s care was therefore compromised by a lack of leadership accountability. Relatives and some people told us they did not feel the service was run well or effectively.

We also found leaders were not visible within the service and did not lead by example. Their absence meant staff lacked guidance, oversight, and clear expectations about the quality of care they should deliver. Importantly, leaders had not driven the necessary improvements identified between 2 consecutive assessments, leaving people at ongoing risk of poor and unsafe care. This demonstrated leaders were not competent in the roles they were assigned and were unable to provide the capable, compassionate, and inclusive leadership required.

People did not feel they could speak up and that their voice would be heard.

Where people had spoken up and reported concerns, these were not always accurately recorded, and there was not always evidence of a clear investigation into the issues raised. This meant concerns were not taken forward, leaving people at risk of harm and without assurance that their voices were valued or acted upon. The absence of effective recording also limited transparency and prevented learning across the service.

Staff did not report concerns about people’s behaviours or challenge inaccurate recording by colleagues, even when they were aware of these issues. This created a culture where unsafe or poor practice was allowed to continue unchallenged, directly impacting the safety and quality of people’s care. Although staff told us they knew how to report concerns and felt confident in theory to do so, in practice no staff exercised this right. This showed there was a disconnect between staff knowledge of procedures and the service culture, which discouraged or prevented staff from raising issues.

People were left at risk of unsafe care because concerns were neither raised nor addressed. Staff were not supported to act as advocates for people using the service, and the culture of silence meant opportunities to improve care and protect people’s wellbeing were consistently missed.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Team members represented a range of cultural backgrounds and were proficient in multiple languages, including Punjabi and Polish, which supported effective communication and helped meet the varied needs of people. Staff reported feeling respected, valued, and supported in the workplace, with no concerns raised regarding unfair treatment or discrimination.

Recruitment practices aimed to attract a diverse workforce staff told us they felt they were treated equitably.

However, during review of staff meeting minutes, it was observed that staff feedback was not consistently accepted, and inclusivity in open discussions was not fully supported. Staff were sometimes not treated equitably during these discussions, which may have limited opportunities for all voices to be heard and valued.

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 service’s governance and quality monitoring arrangements were not effective in ensuring safe, high-quality care. The service had a KPI document which was intended as the overarching audit tool, covering accidents, incidents, weight loss, safeguarding alerts, skin integrity, and complaints. While it provided some descriptive data, it failed to identify key issues, such as staff not consistently recording incidents on the electronic care system, making the data unreliable. There was no evidence that analysis led to actions to address issues or mitigate future risks.

A falls analysis document consisted only of pre-populated charts showing the number and type of falls and their timing, with no interpretation or analysis to reduce risk. Supplementary monitoring records, such as repositioning charts, food and fluid intake, and ABC charts, were not reviewed, and no actions were taken to address discrepancies or shortfalls. Call bell audits showed multiple occasions where people waited longer than expected for support, with some waiting over 8 minutes. No analysis of these delays or actions to improve response times were evident.

The registered manager’s monthly audit reported that all food and fluid charts were spot-checked, all accidents and incidents were recorded appropriately, complaints were managed, and notifications were sent to CQC. Assessment findings contradicted these statements, demonstrating that the audit did not reflect practice accurately. The Service Improvement Plan (SIP) also recorded multiple areas as complete, which remained a concern during assessment. Issues included the recording of thickener, comprehensive ABC chart completion and review, bowel monitoring, care plan updates, lessons learnt from accidents and incidents, and documentation of refusals of care.

Overall, governance arrangements failed to provide effective oversight, ensure accurate auditing, or prompt appropriate follow-up actions. Key safety and quality processes were not embedded, leaving systemic weaknesses and ongoing risks to people’s safety and care.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.

Leaders and managers did not demonstrate effective partnership working. Feedback from external partners, including the local authority, was not accurately shared, and feedback from our assessment was not communicated reliably by the provider. Information shared by management with partners was often misleading or inaccurate, and communication was not open or honest, failing to reflect the true quality of care observed during the assessment.

There was minimal evidence to show people had meaningful access to the wider community. While there were occasional visits from local faith communities, opportunities for people to engage with external groups or community activities were limited. Overall, partnership working and community engagement were underdeveloped and did not consistently support people’s social, cultural, or spiritual needs.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people.

At this assessment, provider-wide learning was not evident. Previous breaches of regulations 9, 12, and 17 had not been addressed and, in some areas, the quality of care had further deteriorated. As a result, there was no evidence that the previous warning notices issued for regulations 12 and 17 had been met. This failure to act on previous concerns directly impacted people, leaving people at risk of unsafe care, poor outcomes, and unmet needs.

Further deterioration in the quality of the service led to additional breaches being identified at this assessment, under regulations 13, 18, and 19. These failures affected the safety, wellbeing, and overall experience of people using the service, as essential care processes remained incomplete or ineffective.

Since the last assessment, managers and leaders have not implemented safe or effective systems to drive improvement. The Service Improvement Plan (SIP) and associated action plans were not adequately monitored or evaluated, meaning issues were not addressed in a timely or consistent manner. The lack of robust oversight and learning has resulted in persistent shortfalls, leaving risks unmitigated and preventing the service from delivering improvements that could benefit people’s care and outcomes.