Cabrini House 1 (Diagrama Healthcare)

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• 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 inspection we rated this key question Good. At this inspection 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.

We did not assess all the quality statements within this key question. We did not identify concerns relating to these areas which we judged as being met at our last inspection.

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.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

Staff were supported by capable and inclusive leaders. The registered manager managed Cabrini Houses 1, 2 and 3. These are 3 services on the same site. Each house had a dedicated coordinator who oversaw the service alongside a dedicated staff team. The registered manager had managed the service for 5 years. They were knowledgeable about their responsibilities regarding the Health and Social Care Act 2014. They were aware of the types of significant events which they were required to notify CQC about and records showed the service had submitted notifications to CQC where needed. The registered manager told us they felt well supported by senior managers. They attended regular quarterly managers meetings where they learned about and shared good practice.

A staff member told us they were well supported working by the registered manager. They said, “The registered manager is doing a great job. She is always available and very supportive.” Management support was available for staff when they needed it. There was a 24 hour on-call number where staff could contact managers if they need any advice or support.

A person using the service told us, “I see the manager when she comes here, I like her, she is kind.” A relative commented, “The registered manager has a warm personality. Things have been more positive since she came here. She is empathetic and willing to listen to me.”

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider had effective systems for monitoring and improving the quality of the service. They used a quality monitoring system which reflected the CQC’s key questions of safe, effective, caring, responsive and well led. We saw a report from May 2025 that indicated they were 98% compliant with the key questions. We saw records confirming that regular medicines, health and safety, infection control and care plan audits were being carried out.

We saw reports from out of hours inspection spot checks carried out in August and September 2025. These checks covered staff presence, the use of appropriate PPE, security, service user engagement and observations. The report included an action plan, for example, staff were reminded to keep the kitchen locked when they were not present as minor maintenance work was in progress.

We also saw a Quality Assurance Framework (QAF) report from the local authority that included recommendations for the registered manager to action. We saw that these actions had been taken for example, people’s hospital passports had been reviewed and updated, and daily logs indicated how 1-1 hours were being used.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.