Chaucer 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 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.

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. We identified a closed culture at the service. A closed culture is a poor culture that can lead to harm and people’s human rights breaches such as abuse. Staff at all levels had not prioritised safe, high-quality, compassionate care. Staff shared there was a low morale at the service and that they did not feel supported by senior leaders.

We found there was a culture where staff were fearful to raise incidents or concerns and this had a direct impact on people they supported, for example delays in seeking medical support. A recent staff survey highlighted their concerns in relation to the culture and direction of the service. One question asked of staff was if they felt confident about the direction of the organisation and over 40% of the staff responses were negative.

People shared they had observed tension between staff members, for example one person told us they overheard a senior member of staff shouting at a staff member. They told us, ‘staff name] has raised their voice and used inappropriate language in front of other staff, calling them “stupid”.’

Staff shared their concerns regarding the morale, one staff member told us, ‘The morale is not very good, staff don’t feel supported very well.’

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, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

Leaders at all levels were not always visible nor led by example. Relatives told us that leaders were not always visible at the service. One person told us, ‘I’ve never seen [registered manager] go in rooms, managers need to know what’s going on, I’ve not seen [registered manager] in the dining room, only seen them in the office.’ And ‘There was a resident’s meeting last week, I brought up that there are no managers at the weekend, it’s disturbing.’

A recent staff survey highlighted their concerns in relation to the leadership at the service. One question asked of staff was if managers role-model the behaviours they expect from others and over 50% of the staff responses were negative.

Staff shared they did not feel supported by leaders at the service. One staff member told us, ‘Staff feel seniors are supportive but higher up no support, that’s if they want to go and report and issue.’

People and staff did not feel they could speak up and that their voice would be heard. Leaders did not encourage staff to raise concerns or promote the value of doing so. For example, we found incidents of abuse and unexplained bruising that has not been reported or escalated by staff. People also shared with us that whilst they may raise a concern, they did not feel these were acted upon, which discouraged them to raise concerns in the future. For example, one person told us, “I get told “It’s a cultural thing… I can’t complain, I’m told its cultural or someone gets shouted at.”

The provider gave staff the opportunity to share feedback in the form of staff surveys and staff responses highlighted concerns. Whilst staff had systems in place for staff to raise concerns such as team meetings, these were not effective. Staff told us they did not always have supervisions, and the supervision matrix shows staff did not have regular supervisions, where they could be supported to speak up.

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

A recent staff survey highlighted their concerns in relation to equality within the workforce. One comment stated they wanted, ‘A good manager who doesn’t have favouritism and only supports their nationality staff and is very rude to other members staff and residents.’ Another comment detailed, ‘Encouraging team work more to reduce the division between day and night staff. Open door policy and inclusivity.’

The provider had not ensured they had effective systems in place promoted staff wellbeing. Staff also shared with us they felt discouraged in their role, one staff member told us, ‘Management come out and say no one has done anything, they don’t address the person who has not reported, we feel really discouraged, the people who aren't doing anything get away with it.’

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 provider did not robust and effective monitoring systems in place to ensure people received safe care that met their needs and preferences. Audits and spot checks were carried out for all areas across service delivery, however these were not effective. For example, incidents, accidents and ABC records were not reviewed regularly to identify the significant concerns we found during inspection.

The provider had not ensured there were clear and effective systems in place for workforce planning. We found staff were not supported to have regularly supervisions. One staff member told us they were only offered a supervision when they were told something had gone wrong, however this was never followed up. We found staff were not skilled or competent to support people who experienced episodes of distress.

The provider had not implemented relevant or mandatory quality frameworks, recognised standards, best practices or equivalents to improve equity inexperience and outcomes for people using services and tackle known inequalities. Best practice guidance in relation to Dementia care and distress had not been implemented.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. Staff had not been transparent in relation to people’s health needs when collaborating with external agencies and stakeholders. For example, staff had not ensured that safeguarding concerns had been escalated to the local safeguarding team.

Some processes were in place for referrals to be made to other healthcare professionals, for example, people’s weight was reviewed and referrals were made to the GP or dietician when a concern was identified. We found people had been prescribed supplements if their weight had decreased to where it caused concern.

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.

Processes to ensure learning happened when things went wrong were not effective. For example, when repeated incidents between people occurred, sufficient learning and improvement was not implemented to address the concerns and mitigate the risk of reoccurrence.

Staff were not empowered to share and raise concerns in a safe way in order to encourage improvements at the service. For example, staff spoke of a blame culture when things went wrong.

The provider had not ensured there were robust quality monitoring and assurance systems in place to evidenced continuous improvement and learning. For example, medicine audits were in place, however these had failed to ensure best practice guidance in relation to medicated creams was being followed by staff.