Carlton 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 changed to Outstanding. This meant service leadership was exceptional and distinctive. Leaders and the culture they created drove and improved high-quality, person-centred care.

This service scored 89 (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.

Staff consistently told us they were united by a shared purpose: to promote people’s independence, remove barriers and minimise restrictions, so people could live full, active and meaningful lives. This shared commitment was not merely aspirational; it was evident in everyday practice, decision‑making and, in the way, staff spoke about the people they supported. Staff described feeling empowered to uphold the provider’s values and to actively champion people’s rights, choices and autonomy.

At Carlton House, this commitment was reflected in a comprehensive, person‑centred activity programme. Staff offered people daily opportunities to take part in meaningful and engaging activities. These opportunities enabled people to pursue their interests, supported emotional wellbeing and significantly reduced the risk of social isolation, demonstrating an outstanding, holistic approach to care.

People thrived in an environment that was welcoming, calm and well balanced, where stimulation and relaxation were carefully considered to maximise wellbeing. This approach promoted emotional wellbeing, social inclusion and positive engagement, ensuring people benefited fully from their surroundings and support.

The culture across the service was visibly positive, ambitious and driven by a strong sense of shared responsibility. Staff demonstrated a clear understanding of the provider’s values and spoke with pride about working in an environment where inclusion, respect and person‑centred care were non‑negotiable. This consistent, values‑led culture ensured people received enabling, individualised care, closely aligned with their own goals and aspirations.

The provider had exceptionally 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 always did so with integrity, openness and honesty.

People and their relatives consistently told us they felt confident in the management team and reassured by their presence. They spoke highly of the leadership team, describing them as accessible, compassionate and deeply committed to ensuring the service was well managed.

Staff consistently described leadership as exceptionally supportive and visible. They told us leaders were approachable at any time and genuinely invested in their wellbeing. Comments included, “The registered manager is one in a million, they are there for everyone and help in any way they can, they give 100% all the time.” And “I can raise anything with the registered manager at any time, [registered manager] always has time for everyone, they are very supportive and make me feel valued.” Another staff member told us, “Yes 100% - when it comes to approaching [registered manager] they are one of the best managers to approach even if you go to them with negativities, they will always leave it with a positive.” This reflected a culture where psychological safety was firmly embedded. Leaders demonstrated exceptional compassion, capability and inclusivity, creating a culture where staff thrived, people felt safe and valued, and high‑quality, person‑centred care was consistently delivered.

The provider fostered a positive culture where people knew they could speak up and their voice would be heard. Staff told us they felt confident to raise any concerns if they had any, they were also confident concerns would be addressed promptly. They also demonstrated a clear understanding of how concerns could be escalated further if required.

People were supported by key workers who knew them well, enabling them to share feedback using their preferred communication methods. Easy‑read information was available to support people to understand their right to speak up and to help staff ensure these conversations were held regularly and meaningfully. This approach empowered people to express their views and contributed to a culture where feedback was actively encouraged and valued.

The provider strongly valued diversity in their workforce. They had an inclusive and fair culture which had improved equality and equity for people who worked for them.

Diversity within the workforce was actively valued, and leaders promoted an inclusive environment where staff felt confident and supported to be themselves at work. Staff consistently told us they felt respected, valued and included. This commitment to inclusion was reflected in the wide range of activities and celebrations that took place, including Pride events, themed social evenings and support for people to socialise in clubs and community venues that reflected their personal choices. One person told us, “I go to the Pride march every year. “Another said “we have a pride party in the garden, last year we had an Elvis impersonator.”

A dedicated culture corner was in place within the home, providing information about different cultures and religions. This information was available in easy‑read formats alongside more detailed resources to ensure it was accessible to both people and staff. This initiative had been well received and was successfully replicated across other services within the provider’s organisation.

The provider’s approach to equality, diversity and inclusion went beyond meeting regulatory requirements and demonstrated a clear commitment to continuous improvement. Their training academy offered all staff equal access to high‑quality development opportunities, including specialist programmes in leadership, operational practice and bespoke care. Staff were encouraged to pursue learning that aligned with both their professional aspirations and personal development, supporting equitable access to progression and skill‑building.

At Carlton House, leaders built upon this organisational commitment by fostering a supportive culture where staff motivated and encouraged one another. Staff described feeling empowered to develop in their roles, contribute ideas and act as positive role models for colleagues.

As a result, the provider demonstrated exceptional leadership in promoting equality, diversity and inclusion, with clear evidence of a positive impact on staff wellbeing, team culture and the quality of person‑centred care delivered.

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.

Leaders demonstrated clear accountability and consistently met their regulatory responsibilities. Notifications were made promptly to the CQC and local authorities when events occurred that impacted people’s health, safety or wellbeing. Robust auditing and quality assurance processes were embedded within the service and included regular reviews of care records, medicines management, health and safety arrangements, and staff practice.

A culture of continuous improvement was evident throughout the home. This was supported by daily clinical oversight and structured monthly governance reviews focused on improving outcomes for people. Staff took part in daily handover meetings where individual needs, risks and support strategies were discussed to ensure consistent and responsive care delivery.

Where people lacked capacity, staff completed regular checks with both people and the wider staff team to ensure care was delivered in line with the person’s wishes, best interests and the provider’s values. This oversight helped ensure care remained person‑centred and outcome focused.

We were assured that staff understood their roles and responsibilities, and the management team could clearly account for staff actions, behaviours and performance. The area manager provided effective oversight through regular reviews of the centralised internal reporting system, clear action planning and routine on‑site visits. This supported the registered manager, strengthened governance arrangements and helped build trusting relationships with people.

As a result, effective governance and compliance systems were embedded. This framework enabled leaders to deliver consistently high‑quality care, safeguarding people’s safety, promoting wellbeing and improving lives. This was further supported by positive feedback from staff, professionals and relatives.

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.

As part of this assessment, we sought feedback from external professionals who had worked closely with the home and the management team. They consistently described care delivery as strong, highlighting positive staff practice and good experiences for people using the service.

The provider shared learning and information openly with partner agencies and worked collaboratively to drive continuous improvement. The registered manager and staff told us they maintained close working relationships with a range of external health and social care professionals, welcoming their feedback and proactively seeking advice to enhance outcomes for people.

These partnerships included GPs and NHS professionals, learning disability and positive behaviour support teams, and local authority social workers. This collaborative approach supported coordinated care and contributed to positive, person‑centred experiences for people living at the service.

The provider had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcomes and quality of life for people.

Staff at every level demonstrated a strong commitment to reflecting on what worked well for each person and sharing this learning across the team. This ensured support remained consistent, creative, and tailored to individual needs.

Learning was embedded into everyday practice. Staff routinely discussed people’s body language, sensory needs, and behavioural cues during daily huddles, reflective sessions, and team meetings. These discussions went beyond routine processes; they were thoughtful and meaningful exchanges where staff openly shared insights, celebrated successes, and explored new ideas. As a result, people received highly consistent support, regardless of which staff member was providing care.

The service actively encouraged different approaches and flexible ways of responding to situations. When staff identified a new strategy which had helped someone feel calmer, more independent, or more in control, this was quickly implemented, reviewed, and, where successful, incorporated into the person’s support plan. For example, one person took great pleasure in unravelling and winding up an extension lead. They were visibly engaged and happy while undertaking this activity. A staff member explained, “Things don’t have to be big — they just have to be right for the person.”