Cartmel Grange

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 75 (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 very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities.

The registered manager and staff team had driven improvements in the service since the last inspection. Staff, people and their relatives all spoke about positive improvements made in the service since the appointment of the new manager.

Relatives told us there had been some very good changes since the new manager had arrived. We were told the culture of the service had improved under the new registered manager staff said they felt much more supported, and care was more person-centred. A relative said,” The staff certainly appear a happier bunch since she arrived.” People we spoke with had nothing but praise for the registered manager stating how she was always around to talk with and responsive to anything they asked.

Management and staff had a well-developed understanding of equality, diversity and human rights, and they prioritised safe, high-quality, compassionate care. Leadership culture was seen to be positive, proactive and transparent in driving the quality of service. All staff had a shared direction to ensure a high quality of care for people.

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.

We were told by management and staff that the provider level support was accessible, and that they visited the home regularly. The management team were passionate to ensure people had equal access to opportunities to promote inclusivity. During this assessment the management team were very responsive to any concerns we raised and took immediate action to rectify them, improve and learn from them.

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

Regular meetings between the management team and staff took place. Staff were given opportunities to discuss performance via a supervision appraisal process. However, the frequency of staff supervisions had not always been completed in line with the providers policies. The registered manager knew this, and action was taken to implement a plan for these to be brought in line with the company policy. Staff told us they could speak up about anything and were listened to and things were acted on.

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.

A proportion of the staff team were from overseas and the provider operated a sponsorship scheme. The staff we spoke with spoke very positively about their experiences of being recruited and working at the home. Staff told us they felt very supported by management team.

The provider did not always have clear good governance systems in place. There was a range of quality monitoring and auditing in place. However, some improvements were still needed to the audit processes for example the medication audit processes in place were not always effective in identifying concerns we found. There were some ongoing actions and recommendations from fire risk assessments that were still in the process of being addressed. We discussed the auditing tools used with the registered manager and the provider’s nominated individual who told us further detailing in the auditing process would be adopted to ensure capturing the issues we found. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We saw there were clear responsibilities, roles and systems of accountability and these were used to manage and deliver good quality, sustainable care, treatment and support. The management team members were seen to be present frequently in the home and the delegation of responsibilities were clear for the day to day running and oversight of the service. The service acted on the best information available about risk, performance and outcomes, and shared this securely with others when appropriate.

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 and management worked in close collaboration with partners to ensure people received good quality care and their needs were met. The home had developed very good relationships in the local community with several social groups who visited the home regularly and this had improved outcomes for people.

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

Where lesson needed to be learned information was shared with the staff team so any improvements could be implemented. The registered manager demonstrated their drive for continual improvement and development in all aspects of this assessment with a clear determination to ensure the home provided the best care possible.