Chipstead Lake - Care Home Physical Disabilities

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• 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

People, staff and health professionals were positive about the new registered manager and the changes they are making to improve the service. However, we found shortfalls in the monitoring of the quality of the service. There were shortfalls in people’s documentations which were not always accurate and had not been reviewed. There had not been a system in place to make sure incidents were used for learning and improvements. The management had limited contact with groups outside of the providers services, this limited their ability to improve and keep up to date relevant to their people’s needs.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager told us they had worked for the provider for over 12 years, starting as a member of support staff at another location and working their way up through the organisation. They told us this gives them an understanding of the providers ethos and expectations, and they can pass that down to their staff teams. Staff told us, “Chipstead Lake is lovely, it’s a lovely place, the most amazing place, we have been through a rocky time lately with changes in management and at head office, Over the last couple of weeks, they are refurbishing, the rooms and the flooring, that’s a positive thing. With the new manager, it’s completely turned around.” “(Manager) has been here about 5 weeks she is really positive, so calm, she does not react to everything, calmed the staff and she does not let on any worries, it is so calm and different, morale is back up.” “I wake up and want to come in to work." And “The manager is very approachable and gets things done. If she says she is going to do something you can see it starting straight away”.

The registered manager had systems in place to monitor the quality of the service and ensure people were valued and respected. This included an ‘open door’ policy and various meetings where people were included and asked for their opinions and choices.

Feedback on the new registered manager was wholly positive. There had been managerial changes at Chipstead Lake in the last 12 months and staff were hopeful that the current registered manager would continue in their role for as long as possible as the progress they had made already had a positive impact on them. We were told, “Our new manager is a really nice, there is a sense of calm there, she thinks about things and gets on and deals with them, I am very confident with her, she is not new to Leonard Cheshire, someone new from outside would have to get used to the way of working. People feel loyal to the service as everyone becomes our family." " The manager has changed things for the better, the old manager was good but the new manager seems to be getting more done and more works are appearing on the premises and will make it look better and people will take ownership of it and look after it.”

Leaders at the service including the registered manager, deputy manager led by example, both provided hands on care when needed and to support staff where required. Issues we raised with the registered manager were accepted and they told us a plan would be developed to address these. Many of the shortfalls or issues we identified did not come as a surprise to the registered manager and many had progress towards improvement already started.

Staff told us they felt confident to raise concerns although we did not see any evidence that this was happening. Staff told us, “We have a whistleblowing hotline so I can report to the hotline, then the area manager.” and, “Definitely, I am not shy in speaking up if I felt something was wrong, I would go to the registered manager and get it sorted, it’s better to deal with things before they escalate.” We were told by the registered manager that there was an incident between a person and staff, The staff member had to come and ask for assistance from the registered manager. This was not recorded in evidence supplied to inspectors. By not recording these incidents, there was a risk people's care and support plans, would not be based on accurate information. Staff said that the registered manager were around and easy to talk to whilst remaining managerial.

The provider had policies and procedures in place to support staff to speak up about any concerns they have. The processes offer staff protection to whistle blow about any concerns without fear of discrimination. However, incidents had happened that had not been reported or recorded.

The staff told us that they felt there was an equal and diverse workforce at the service. Staff told us, “Yes, I have not come across anything like someone who has not been put forward for anything they want to be, like team leading.” Another staff member told us, “I believe it’s diverse, we’ve got males, females, people of different ethnicities and ages, if they want to progress regardless of ethnicity, gender and age, they can. If team leading is what they want, they want to progress, they must go through rigorous training and prove themselves, the diversity and process is open and fair.” And “We have a very diverse staff group here. For many years we only had one man and that was unusual, it has changed a lot. We used to have gap students, and they came from all over the world, they spent 3 months in care and 3 months doing activities and they could tell us about their culture, it prevents residents becoming insular.”

The provider had an Equality, Diversity and Inclusivity policy which was available to all staff.

The registered manager told us they would develop their own way of monitoring the service whilst they learnt about the service. They felt that the provider’s monitoring systems were not enabling them to achieve this, and they produced evidence of audits whilst we were on site. Both the registered manager and deputy manager, were transparent about documents not having a date when completed recorded, stating that they used to be required to date all paperwork, but this had been changed by the provider. The operations manager told us, the service would be moving to an all-digital paperless system imminently, however, in the interim the registered manager would keep important monitoring systems in paper in their office.

The provider had a governance framework in place but this system was not working well and were not fully embedded at the service. The registered manager had decided they would change the governance records so they could have oversight. People’s care plans were not dated. There was no space for a date on the provider’s paperwork, we could not be assured information was accurate and up to date. The name of the person writing the care plan was not included and there was no record on the document to evidence if people were involved in writing their care plan. Some care plans were inaccurate. The guidance given in one person’s care plans referred to them living in the main building, however they were living in another part of the service. This meant the guidance given to staff was not correct as the plans had not been updated to reflect the different living arrangements. There were other examples where we found the information in care plans was incorrect because of what staff told us or what we had observed. Other care documents were also undated such as profiles and health information. Some people had planned goals and some people did not. However, the goal plans recorded had not been fully completed, many parts had been left blank. One person had 6 separate goals recorded. The documents were all incomplete, the date recorded to achieve each of their goals was 31/12/23. No further information was given, sections to complete 3 and 6 monthly reviews and the final outcome were all left blank. There was limited understanding of what goal plans were for and how staff could support to achieve positive outcomes.

The incidents which people had been involved in had not always been recorded and reported. People were at risk of not receiving appropriate support as staff and health professionals would not have all the information to make informed decisions about people's care and support needs.

Staff told us they work well with professionals who visited the people they support. The registered manager told us they did not engage in any local forums to engage and share ideas with other local providers or external agencies. They only engaged with other staff and managers within the provider’s network of services.

Feedback on the new registered manager was positive. Partners felt they had already developed a good relationship and felt that they were open and honest and the person to drive the change needed. They felt the registered manager's experience would lead them to make changes for the better and this would have a positive impact on people. We were told “the registered manager just gets it. We feel they know how to work with us and will keep us up to date as necessary. I feel that with (registered manager) the service will get to where it needs to be, and we are looking forward to working with them ongoing.”

There was evidence not all incidents which we believe to have happened had been reported to the relevant authorities. There have been at least 2 incidents we were made aware of which would have required a notification to CQC, which had not been received. When discussed with the registered manager they believed the previous manager had done this. We asked the registered manager for their records of notifiable events however these were not received. The registered manager later confirmed there were no records of CQC notifications being made.

The registered manager told us of incidents that had happened and had not been reported internally or to the relevant authorities.

Some incidents had not been reported and recorded, therefore a robust process for learning lessons to ensure incidents were not repeated, to improve outcomes for people was not evident.