Chase Lodge Care Home

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

We identified a breach of regulations. The provider had systems and audits in place, however improvements were needed to ensure these were consistent and effective. For example, in relation to medicines management and the submission of CQC notifications. Changes were made to make improvements after our visit. We did not find any evidence of harm to people, but this was a breach of regulations relating to good governance. The provider was making changes to management structures and trying to recruit staff. Staff and leaders felt achieving this would improve the service overall. Everyone we spoke with during this assessment gave positive feedback about the culture and leadership of the home. Staff and leaders were committed to providing a good service to the people who lived there. People were supported to take part in activities which were meaningful to them. They were also encouraged to maintain relationships with friends and family. There were well established links with other professionals which supported good care provision and joined-up care. Staff received training and understood equality, diversity and human rights principles. They built trust with people and understood the unique challenges they faced. The provider was keen to ensure everyone felt included and valued in the organisation. There were positive relationships between the staff team and other professionals. This helped improve care provision for people and enabled a joined-up, consistent service. We saw evidence that, when concerns were raised or suggestions made, the management team listened and addressed these. Managers were open to ongoing learning and improvement.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff and leaders promoted a positive culture and were committed to providing a good service to the people who lived there. Staff were aware of the importance of equality and diversity and respected individual needs and preferences. They built trust with people and understood the unique challenges they faced. Staff we spoke with were positive about the leadership of the management team. The management team maintained a visible presence within the service.

Regular team meetings, handovers and supervision helped staff to feel involved in the service and kept updated about any risks or challenges. There was oversight by the provider to monitor progress, standards and plans, although it was acknowledged there had been some shortfalls.

People, their relatives and staff were confident about the leadership of the home. Staff felt the management team were approachable, fair and supportive. During this assessment, members of the management team were present and engaged, and were open to challenge and feedback. The registered manager told us they received regular supervision and felt supported by the provider and other managers. After the site visit, the registered manager made changes to their CQC registration and the service management arrangements. This meant they would have more capacity and oversight of Chase Lodge. A professional told us managers from the service attended local meetings for care home managers. They said information about various topics and training were shared. They felt, “This demonstrates an interest in keeping up to date with changes within the system and keeping up to date with best practice.”

The registered manager had the skills, knowledge, experience and credibility to lead effectively and were open, honest and responsive during this assessment.

There was a positive culture where staff felt they could speak up and their voice would be heard. People and staff felt confident that the management team would listen and address any concerns they had. The only area for improvement from people and staff related to recruitment and permanent staffing. We received assurances that this was being addressed.

Staff had access to whistleblowing policies and systems were in place to support them when identifying concerns or raising issues. A complaints process outlined how people could raise concerns if they were unhappy with the service. Feedback from people and staff was gathered via resident meetings, key worker meetings and surveys. Feedback was generally good. We saw evidence that when concerns had been raised, the management team investigated these, and lessons were acted on and shared.

We received mixed feedback from staff who required additional support. We heard a positive example from one member of staff about how their additional support needs had been met, whilst another told us the extra assistance they needed was not always provided in a timely way. Leaders told us about several schemes which supported staff member’s diverse needs. For example, interest free loans, mental health counselling and contracts with improved pay, sickness benefits and holiday allowance.

Staff had access to equality and diversity policies and guidance. These aimed to ensure reasonable adjustments could be made to meet needs such as caring responsibilities or emergency leave requests.

Difficulties recruiting permanent staff and the use of agency staff placed additional responsibilities on staff and managers and impacted on information sharing and continuity of care for people. The registered manager told us they planned to cancel their registration as manager of another service as the needs of both services were more than could be met by one person. The registered manager knew staff well. They told us they had taken action where the behaviour of staff and agency staff had fallen below the standards expected. Staff confirmed they had been involved in these procedures. Staff told us they had regular contact with the registered manager and deputy, and this helped them to promptly discuss issues, challenges or changes.

During this assessment, we found governance and accountability systems were in place but not always effective. A range of checks and audits were in place to monitor the quality and safety of the service. These included reviews of care plans, medicines, infection prevention and control audits and mock inspections carried out by the provider. However, these governance systems were not always effective in identifying and addressing issues we found during the assessment. For example, in relation to safe medicines management and the submission of CQC notifications. The registered manager told us the latest medication audit had not been completed due to staff sickness and CQC notifications had not been submitted because of an oversight. During the assessment, we found several areas of shortfall which the provider had not identified. The provider took prompt action to respond to the concerns raised and improve their governance systems and practices. It is noted that improvements have been required to service leadership, management and governance at this service for the previous 4 inspections.

People and their relatives told us staff supported them where necessary to make appointments or visit health and social care professionals. One person explained they had received specialist medical treatment and then had to make a decision about future options. They said, “Staff really helped me to make sure I made the right decision.” The staff team worked with other professionals to provide a service which met the full range of people’s individual needs.

The registered manager told us the service worked in partnership with health professionals including GP, pharmacist and mental health nurse. In addition, there was regular support from district nurses and people’s individual care coordinators. Good relationships with other professionals helped improve care provision and supported a joined-up, consistent service. Staff told us they appreciated the contact they had with other professionals. One staff member said, “We have a weekly visit from the GP and mental health nurse, it’s a really good service.”

We received very positive feedback from health and social care professionals. They told us staff worked in partnership with them to achieve good outcomes for people. Professionals told us information was shared proactively to support good care provision and joined-up care. One professional said, “The management and care staff work together to maintain safety without depriving people of their liberty. They will communicate and discuss different situations with [health professionals] and are happy to have a multi-disciplinary approach.”

Arrangements were in place to ensure staff had a good level of partnership working with other agencies and professionals. Relevant information was shared with professionals as required. Staff and leaders were open and transparent during this assessment process and engaged fully with the inspection team.

Staff and leaders demonstrated a good understanding of the challenges faced by the service and its areas of strength. Staff were encouraged to raise concerns and make suggestions to ensure people received the support they required. In a recent staff survey, a member of staff had asked to do more in depth training around mental health. This was being supported by the management team. Managers and the staff team were committed to providing a high quality service. During the assessment managers acted promptly to address suggested improvements.

The provider had a live action plan which identified some shortfalls and ensured change and learning followed. Issues found during the inspection were added to the action plan for follow up.