Culrose 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 inadequate. At this assessment the rating has changed to requires improvement. This meant the management and leadership was not always consistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service had been in breach of legal regulation in relation to governance at the service. At this assessment we found the service was still in breach of this legal regulation.

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.

Though the provider had a vision, strategy and culture, staff were unaware of this. 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.

Staff spoken to were unclear on the strategy and vision but they felt involved in ways to improve the service. The provider had created a positive culture. Staff were happy in their role and felt they had the training and support they needed. They enjoyed coming to work with the people they supported. The provider had an ongoing action plan for improvement and had made significant progress in addressing areas of shortfalls from the previous inspection, including environment and care records, although further work was needed.

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.

People, families and staff spoke positively about the registered manager. One relative said, ‘I trust [registered manager] 110%. My [person] loves [them] and is always pleased to see [them]. [They] are approachable and easy to talk to.’ Another told us, ‘The care is very good. The manager is a positive person with a great attitude. We chose the home after meeting the manager and have not been disappointed.’

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

Staff were aware of the whistleblowing policy and felt confident if they raised any concerns they would be listened to. There were regular staff meetings where staff could share ideas and raise concerns. People and their relatives were invited to regular meetings. A relative said, ‘I think the home are open to listening to reasonable points and suggestions.’ Another said, ‘I’ve been to a couple of meetings to hear what’s going on. The home like feedback.’

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 told us they were treated well by the provider and felt well supported. The registered manage was keen to support and develop staff’s skills and knowledge.

The provider did not always have effective systems of accountability or good governance.

There was a new governance system implemented this year which was still being embedded and adjusted to ensure it provided appropriate oversight and monitoring. There was a variety of checks and audits in place where were discussed by the registered manager and nominated individual on a monthly basis and a provider report produced for the owner from this. These checks and audits had not identified all the issues we identified from this assessment. Further work was needed to ensure the system captured these shortfalls including ensuring compliance with the Mental Capacity Act, oversight and monitoring of medication, consistent bowel and fluid monitoring with appropriate escalation when needed and consistency of care records. This oversight was needed to ensure people received appropriate care and timely actions taken to address any shortfalls. The registered manager was responsive to address areas of improvement we identified.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The provider worked well with other health and social care agencies and feedback from other services was positive. One health care professional told us, ‘Staff at Culrose are well led by their team leaders and are aware of each resident and their needs, their communication and their support requirements. Most of the senior carers are experienced and know their work well. If they have any questions, they are quick to contact us for information and clarification.’ The registered manager had developed relationships with local faith groups who come to support individuals in the home when needed.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. This was shown by the issues we found at this assessment. However, the registered manager engaged with the assessment process and had implemented changes during the process to address these shortfalls. They had established a system using significant event analysis forms to capture negative and positive events to identify what went well and what needed improving. This was reviewed and shared with the staff team to improve performance and celebrate success.