South Chowdene

Since the last inspection in 2021 there have been 6 registered managers, with 4 in the last year, and other peripatetic managers covering at times. People told us this had led to inconsistent support from the senior management, there being limited opportunities to be involved in decision-making, and staff morale being low. However, since the new management team had come into post, people felt improvements were being made and they felt positive about the future operation of the service. Visiting professionals reported improved communication and safer care in recent months.

Care was generally person-centred, and staff worked collaboratively with professionals to support people’s health and wellbeing. We observed warm, compassionate interactions and staff demonstrated good knowledge of residents’ needs. However, care planning and assessment processes required improvement. Standard templates lacked flexibility for short-term admissions, and there were gaps and inaccuracies in documentation that could affect decision-making. Although staff sought consent during care interactions and involved families in best-interest decisions, Mental Capacity Act (2005) principles were not always applied correctly. The new registered manager took immediate action to resolve these issues.

South Chowdene routinely provides care and support to large numbers of people receiving end of life care and so the needs within the home can change rapidly. The dependency tool did not fully account for fluctuating needs, such as end-of-life. Relatives praised continuity of care since the appointment of a permanent manager and described the new leadership team as approachable.

People’s nutrition and hydration needs were met, and staff adapted menus despite budget constraints.

Governance systems had not consistently identified these risks, and audits were not always effective. For example, we found gaps in medication administration records, unclear codes and care records.During the recruitment process the provider was ensuring staff provided a full employment history and agency staff profiles did not always record people’s right to work or the dates they completed training or have current photographs. The registered manager acted promptly to address these issues and strengthen oversight.