Cartref 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 good. At this assessment the rating has remained 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 68 (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.

Leaders and staff understood the purpose of the service was to support people with complex needs to develop their independence and ensure a good quality of life. Staff demonstrated this in practice. People were supported to set goals, take part in daily tasks and pursue education and community activities. Staff knew people well, and our observations showed warm interactions. People appeared comfortable with staff and spoke positively about their support. Staff we spoke with described a supportive team and said they could seek help from leaders.

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.

Leadership responsibilities were shared between the registered manager, deputy manager and team leader. Leaders were visible during the assessment, supported staff when people wished to go out and demonstrated detailed knowledge of people’s risks, preferences and goals.

Leaders had relevant knowledge and experience and understood the emotional, behavioural and physical needs of people living at the service. The registered manager had developed specialist knowledge of positive behaviour support, safeguarding and supporting people who experienced emotional distress. The registered manager kept up to date with changes in adult social care and attended forums and meetings to support this.

Staff described the registered manager as knowledgeable and said leaders understood what worked for individual people. A staff member told us they felt supported and could approach the manager when they needed help.

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

Staff knew how to raise safeguarding concerns and described reporting concerns to the management team. They also knew they could contact the safeguarding authority if concerns were not resolved internally. A staff member told us they could voice concerns openly, felt supported by management and believed colleagues would help when needed.

Whistleblowing and safeguarding were discussed at team meetings. Records showed leaders reminded staff to be honest, raise concerns and remain focused on people’s wellbeing. Staff were also offered opportunities to speak through supervision, team meetings, and direct discussions with managers. People could provide feedback through meetings and individual conversations. Records showed people had raised requests about activities, privacy and the environment, and changes had been made in response.

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. For example, the provider’s recruitment processes had been reviewed to improve accessibility and reduce bias.

Staff had completed equality, diversity and inclusion training. Staff had access to development opportunities, qualifications and leadership training. Supervision records demonstrated that leaders promoted workforce equality and inclusion.

Staff described feeling supported and able to approach the registered manager if they needed help or an adjustment. Flexible working arrangements were used, including support for staff who balanced work with study or other commitments.

The provider had not always had effective governance and management arrangements.

Senior leaders were open about areas of the service they wanted to improve. The nominated individual told us they had identified their previous governance arrangements had not been sufficiently effective to maintain robust oversight of the service. They told us they had made recent changes to their governance systems, and some systems were still being embedded. Leaders required greater familiarity with their electronic system to support effective review and oversight of the service.

A range of checks and audits were in place including for accident and incidents, care planning, medicines, infection prevention and control and health and safety including environmental checks and fire safety. The checks and audits in place had identified some issues and led to some actions and improvements in the service. However, we found they were not sufficiently robust to identify or effectively resolve some of the issues we found in relation to risk management and care records for example around constipation. Audits identified ongoing medicine stock issues, and these were investigated and resolved at each audit however the issue remained ongoing at the time of the inspection. We also found some issues with complete and accurate records for mental capacity documentation. Audits did not always clearly record the sample reviewed or demonstrate how conclusions had been reached and actions did not always consider how to prevent future re-occurrence of the same issues.

Prior to the inspection concerns had been raised about staff practice in relation to professional boundaries. The provider told us there had been some historic concerns and they had taken action to address this. During the inspection, we saw recent team meetings aimed to reinforce respect and professional boundaries. Although we observed mainly positive and kind interactions between staff and people, we found there were some areas where how staff supported people to understand boundaries in a professional manner could be improved.

Leaders responded openly to feedback during the assessment. They had taken some action to address some feedback and told us they would take further action to improve the service.

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.

Staff made referrals and worked with GPs, mental health teams, hospitals, social workers, commissioners, pharmacies, dentists, opticians and other specialist services. Records showed people attended health reviews and appointments and were supported to access urgent healthcare when needed. A professional described the provider as responsive and collaborative.

People accessed local shops, cafés, parks, leisure facilities, community events and public transport. Staff helped people maintain contact with families and those important to them.

People were supported to maintain relationships with those important to them including familial, friendship and romantic relationships.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always actively contribute to safe, effective practice and research.

Not all staff were up to date with their refresher training in line with the provider’s training programme. Although the registered manager had identified this and booked some staff onto training between September and November 2026, training compliance had not been effectively addressed to ensure staff training remained in-date and that all staff had completed specialist training from the training programme.

Staff and leaders discussed incidents involving each person at monthly meetings and used an electronic dashboard to review the number and type of incidents over time. However, learning was not always clearly recorded or evaluated for effectiveness. The providers external audit found learning was often shared anecdotally and required better documentation. We found some recurring themes across meetings and audits which demonstrated actions had not been sufficiently robust or effective to drive and sustain improvement.

Leaders responded to inspection feedback and acted. These actions demonstrated willingness to improve, but the provider needed a more systematic approach to ensure learning was recorded, shared, implemented and checked for sustained effectiveness.