Chesford Grange 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

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 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 the overall governance at the service.

This service scored 36 (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 based on transparency and upholding human rights. However, they were not always assured people’s rights were promoted. Some people’s rights were restricted without legal authorisation. This put people at risk of harm.

People’s rights to dignity and privacy were not always promoted and the culture of the organisation did not always respect people’s choices. Some people experienced unauthorised restrictions. This put people at risk of harm.

The culture of the organisation did not focus on ensuring people lived in a safe environment which was subject to regular internal health and safety checks. The provider had failed to act on the absence of health and safety checks for 2 months.

Staff told us they promoted people’s rights. However, some of our observations found the culture was not inclusive and did not reflect people’s autonomy.

The new manager responded to our feedback by introducing new systems and training, and staff told us they had confidence in the new manager’s leadership ability.

At the time of this assessment, the provider did not have inclusive leaders who had the skills, knowledge and experience to lead effectively. Risks to people were not managed safely, environmental risks were not monitored, and people’s choices were not promoted. Concerns raised from the previous inspection continued to be found, this meant the provider was not assured lessons had been learnt from the previous inspection. This put people at risk of harm.

However, a new manager had just started within their role and was in the process of registering with us as registered manager. They were proactive to our feedback. One staff member said, “There were a lot of issues before, but since the new manager started it’s starting to settle.” Another staff member told us they felt confident things would improve under the new leadership.

Staff did not always feel confident their concerns would be listened to. One staff member told us they raised concerns about a staff member’s conduct with the previous management team, but nothing was done. Another staff member told us they were unsure about raising concerns with management. However, a further staff member told us the new manager discussed the whistle blowing policy in a recent team meeting and felt confident to raise concerns with the new manager.

A whistle blowing policy was in place and the provider had a ‘you said, we did’ board to encourage people, visitors and staff to raise concerns and speak up.

The provider did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them. Whilst the provider carried out recruitment health questionnaires to ascertain whether staff had any health issues prior to employment, where staff indicated they experienced health issues, the provider had not completed any risk assessments to indicate how they would be supported in their duties.

Staff told us they were treated fairly by the provider. One staff member said, “There is a good sense of teamwork working here, we all support each other. It is a good place to work.”

The provider did not have clear responsibilities, systems of accountability and or quality monitoring processes. The provider failed to monitor and respond effectively to risks people experienced from their health conditions. The provider failed to ensure staff had the knowledge, competence and skills to carry out their duties and to ensure clinical staffing levels matched the dependency tool. The provider failed to complete audits of internal health and safety checks and ensure the physical environment was maintained to reduce the risk of infection. The provider failed to audit people’s restrictions and complete best interest decisions to ensure people were not subject to unlawful restriction. This put people at risk of harm. Where safeguarding concerns were raised with the local authority the provider failed to follow their statutory notification obligations by notifying us about these safeguarding concerns.

The new manager had only recently started in their new position and was responsive to all of our feedback. They introduced new quality monitoring systems and processes, audits and all unauthorised restrictions placed upon people were lifted. We will review the success of these systems in the next inspection.

Staff told us they were positive about the new manager and felt improvements were already being made.

The provider did not always uphold their duty to collaborate and work in partnership. Where health professionals had advised people’s health conditions required more frequent monitoring, their advice was not always followed. However, one visiting professional told us the provider worked in partnership with them and kept them informed with changes in people’s health.

Minutes of meetings documented the provider worked in partnership with other professionals and staff told us they worked with other health professionals such as physiotherapists and doctors.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. During the last inspection we raised concerns over risk management, supporting people safely with diabetes, escalation of incidents and overall governance. These concerns were again found during this inspection, this meant the provider failed to improve the quality and safety of the services provided in the carrying on of the regulated activity. This put people at risk of harm. The new manager was responsive to our feedback and took immediate action by implementing new systems and processes to monitor the care and support people received. We will review the success of these new systems in our next inspection.

Staff told us they felt positive about the new changes in leadership going forward.