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.

This is the first inspection for this newly registered service. This key question has been rated inadequate. The provider is in breach of a regulation in relation to good governance. Quality assurance systems and processes were not operated effectively, and there had been a failure to identify and address areas requiring improvement. Oversight of the service was lacking, and we found breaches of regulations in relation to safe care and treatment and person-centred care. The leadership team had failed to learn lessons from incidents and act on areas for improvement, which placed people at the continued risk of harm. Intervention was required to improve the culture at the service in order to ensure all staff felt confident in the approach of the management and leadership team. Staff need not always feel they were able to speak out and when they did, they did not always feel their concerns were listened to and actioned.

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.

We received mixed feedback from staff about the leaders of the service. Staff did not always feel supported and listened to. Feedback included, “If we try to bring things up in a meeting we are not listened to,” “The [registered] manager pushes back when staff have ideas,” “I feel like night staff are abandoned [by management],” “The [registered] manager is approachable and understanding” and “The [registered manager] is very good.”

There was mixed feedback given regarding the culture of the service. It was evident when speaking to some staff that they felt the culture was not always open and transparent and that there were perceived consequences for certain actions. For example, not attending staff meetings. Positive comments included, “We always support the residents as a team and work together [with managers],” “It’s been a lot better the last 3 months” and “There is a big shift, and some staff get along better than they did.”

The regional manager told us the culture was an improving picture, and the registered manager told us about some challenges that had arisen when managing the staff team and performance.

We observed good teamwork during the assessment.

Systems and process in place were not always effective in promoting an open and transparent culture whereby all staff felt understood and comfortable. The processes in place had not ensured the delivery of person-centred care for all people.

Staff did not feel leaders were always visible, compassionate and inclusive. Some staff felt communication from the leadership to staff team was lacking. Feedback included, “We never see any of the management team, [I am not] valued at all. I feel so insignificant. When we say something is wrong, no one listens,” “If we say anything [about staffing] we are told to just manage. [The registered manager] never ever comes on the unit we never see [them],” “I don’t really see the [registered] manager,” “Communication is not good. Nothing gets done” and “Communication is poor.”

We did however, observe good communication taking place between the registered manager and staff during daily flash meetings.

There was consistent leadership and a registered manager in place at the service. However, systems and processes in place had failed to support and establish effective leadership, whereby the culture and values of the workforce were supported and understood by the management team.

Some staff felt able to speak up, however other staff did not. One staff member told us, “It is hard to speak out.” Another staff member told us that staff meetings could be improved if managers did not “push back” when staff raised concerns.

Systems and processes in place did not always effectively support all staff to feel confident to speak up. Whilst there were opportunities for staff to share ideas and concerns in staff meetings, daily flash meetings, and supervision sessions, they did not always feel able to.

Diversity in the workforce was evident. Some staff told us the registered manager treated everyone fairly. Feedback included, “All staff are treated fairly” and “The [registered] manager is definitely fair.” However, not all staff felt fairly treated and it was clear from our conversations that there were mixed feelings regarding the leadership style of the registered manager.

Policies in place supported equality, diversity and inclusion. However, these required further embedding to ensure all staff felt fairly treated and equal.

Leaders were able to speak about the management and governance structure. However, they had failed to effectively implement this and identify the failings which had impacted on the quality and safety of the service.

The management team accepted accountability for errors which were raised by the assessment team throughout the assessment process and during feedback. They told us they were seeking to make immediate improvements as a result of the concerns raised.

Quality assurance systems and processes were not implemented effectively and consistently. There was insufficient oversight in relation to the quality of service provision. Systems and processes were not implemented robustly to ensure people received safe care and treatment. Matters identified through the assessment process had not been picked up through the management team’s quality checks. For example, risks relating to pressure care, weight monitoring, medicines management, equipment checks, fire safety, safeguarding, recruitment, and lack of person-centred care. There had been a failure to ensure accurate complete and contemporaneous records were maintained.

People were not always provided with the opportunity to access the local community. However, people did receive support from health professionals when needed.

The regional manager told us about ongoing partnership working with the local authority safeguarding team. Staff were able to tell us about partnership working with health professionals. However, further improvement was needed regarding some external partnerships with key stakeholders.

Partners raised concerns regarding quality and safety of service provision. However, health professionals felt that the service worked well in partnership with them.

Systems and processes were in place to support partnership working. However, this required further embedding into practice to build more effective relationships with some partners.

The leadership team had failed to learn lessons from incidents and act on areas for improvement, which placed service users at the continued risk of harm.

Staff gave mixed feedback regarding leaders considering suggestions and making changes. One staff member told us, “I raise things like people wearing each other’s clothes, but nothing improves.”

Systems and processes in place were ineffective in identifying lessons learned and driving improvement. Where concerns were repeated, there was little evidence that lessons had been learned to reduce the risk of repeat incidents. For example, actions for discrepancies in medicines stock counts identified in April 2024 stated, ‘continue with daily medicine counts to identify any issues promptly.’ There was no evidence this had been implemented effectively as there were repeated stock count errors, and this remained a concern during this assessment. In addition, a lessons learned document stated, ‘senior staff must ensure pre-admission assessments are robust’. However, at this assessment, we found there were missing preadmission assessments and gaps in preadmission information. The provider had not identified that this action had not been implemented and had continuously failed to monitor whether actions were implemented effectively.