Cassandra House

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 remained as requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. The service was in continued breach of legal regulation in relation to governance and oversight of the service.

This service scored 62 (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 registered manager showed a clear understanding of their role in developing the service's values of dignity and respect. People and relatives were provided with information about how to raise suggestions and concerns about the service. The management team was responsive throughout the assessment in addressing our findings.

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. The provider understood their regulatory responsibilitiesThe registered manager was new in post and being supported to develop into the role. The management team were open, honest and responsive to our findings throughout our assessment and were aware of the improvements needed to systems and processes to improve the quality of the service.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff and people felt able to raise concerns with management and were confident that these would be dealt with effectively. Team meetings and supervisions provided opportunities to discuss issues, and the managers were visible and approachable within the service.

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 felt supported in their role and worked well together as a team. One staff member told us "It’s a nice family place. Everyone gets on with the job. There’s nothing I really don’t like.” They said that they were able to take time off for emergencies or appointments. Staff had completed equality and diversity training. The registered manager ensured staff had opportunities to discuss any training or development needs to suit their role.

Although the provider had systems in place and managers held defined roles and responsibilities, these were not always supported by effective governance or accountability structures. While audits and reviews were being carried out, they often lacked the necessary depth and specificity to identify key risks and issues. This contributed to ongoing breaches of legal regulations, including concerns related to environmental safety, individual risk management, infection control, and medicines management. In several instances, audits failed to detect the issues later identified by the inspection team. Even when concerns were noted, they were not consistently addressed or followed up with appropriate action. For example, medication audits did not include stock control, and health and safety audits overlooked window safety risks. Additionally, the provider did not adapt generic audit tools to reflect the specific needs of the service, limiting their effectiveness in monitoring and mitigating risks or driving meaningful improvements in care quality.

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. Management and staff worked with relevant professionals, such as Speech and Language Therapists, Dieticians, GPs, Social Workers and Pharmacists, to improve people's experience and support. A professional told us, "The service made it really easy to work together." The managers worked closely with local businesses and community clubs to arrange trips for people, such as to the coast or farms.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research. Concerns identified did not always lead to continuous improvement and sharing of learning across the home. Audits lacked detail and therefore failed to identify key risks and drive improvement. The managers were responsive to our findings, and added areas to audits during the assessment.