Carnalea Residential 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 Good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (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, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The provider supported people to be the lead in their care, promoting dignity, respect, and valuing people as individuals.

Staff had a clear understanding of these values. One staff member told us, “The place is homely, and mealtimes are wonderful social events for everyone.” Another staff member told us, “Everyone, from the managers down, is so supportive. You can go to anyone. Staff have such a lot of patience, and I am confident in raising any concerns or asking for advice anytime.”

The registered manager told us they felt being visible was important to enable them to oversee the culture of the service and provide support to staff.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

There was visible and clear leadership in the service. Staff knew who to go to if they needed support to meet people’s needs and told us the registered manager was approachable and supportive. One staff member told us, “I can go into her office anytime and she would listen and support me.”

The registered manager told us, “We are always asking people their opinion, and there is a suggestion box by reception. The staff team are well established, and people and their families know who works here and feel they can speak to anyone.”

The registered manager told us they felt supported by the owner of the service and understood their regulatory requirements in line with their registration.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us they felt confident to voice their concerns about anything in the service to the management team, and to approach external authorities if needed. One staff member said, “The residents are my priority. If I am not happy about something, and not getting the feedback, I would certainly take it further.”

The provider had processes in place which supported staff to speak up about any concerns within the organisation. The registered manager told us they operated an open-door policy and welcomed staff and visitors to raise any concerns with the management team. They told us, “I make sure their voice is heard, and that they know their concerns have been taken seriously. We want staff to feel safe, comfortable and listened to.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff felt they were treated well and supported equally by management. The provider had processes in place to encourage an inclusive culture and support staff well-being. Any issues could be discussed openly at staff meetings or during supervision. Staff told us they would not hesitate to speak to the management team if they needed to. Staff surveys had taken place to gain staff views about how the service could improve, and there were programmes in place to enable staff to develop in their role. One staff member told us, “The teamwork here is very good.”

The registered manager told us they made adjustments to accommodate staff’s personal circumstances. They told us, “We have some staff who like to take certain times off during the week off for religious purposes, and we work their rotas around this.”

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

There were systems in place to support managers to identify and address risks to the service and quality concerns. The registered manager reviewed audits, and quality checks were completed which included health and safety, medicines management, staff training and falls monitoring. Outcomes from these audits were discussed with members of the management team and action plans put in place to address areas required. For example, the registered manager was reviewing the processes around recycling to reduce waste.

The quality of the service was also discussed and shared with people, their relatives and staff. Their views on how to improve the service were sought and taken into account. One person told us, “It’s nice living here”. One relative told us, “The quality of the service provided by the home is excellent”.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. One health colleague told us, “Concerns are referred but there has been a recurrent issue with some senior staff feeling they do not need to refer to the community services as they feel the team won’t come out to support which is not the case”. The registered manager told us that this situation is improving since the implementation of a communication tool which has increased the timeliness of referrals and treatment for people living at the service. Another health colleague told us, “The service makes referrals to us on time, and I can talk to staff with no obstacles. I have always felt part of the team”.

Following a deterioration in communication between the service and some health partners at the start of the year, a communication tool is now in place which has improved the timeliness of referrals and treatment for people living at the service.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The service ensured they continued to learn and improve the service. We noted they had implemented learning from safeguarding incidents and accidents and shared these with the staff to drive improvement. The management team were keen to build links with partner agencies and liaised with the local authority and local integrated care board. The registered manager was involved in forums and events to keep abreast of local and national developments in health and social care. The registered manager told us, “I am open to anything that will support the role and improve the service “.