Callands Care Home

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. This is the first assessment for this service under the new provider. This key question has been rated 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 breach of legal regulations in relation to record keeping.

This service scored 61 (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 was working to develop 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 provider had supported staff with training and coaching to help develop the culture within the staff team. Making improvements remained a focus of the management team. Some staff and relatives noted they were aware of occasional staff disagreements. Where required, managers had been addressing staff performance issues. The management team held regular meetings to help staff work towards the same goals. Meeting minutes demonstrated managers were focusing on areas for improvement but also celebrating successes.

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. However, this needed to be embedded and sustained.

The home manager had applied to register with the CQC, which was completed during the assessment period. They were focused on providing consistency and stability within the home and had made changes to support the leadership of the various units. They understood the people they supported well and were open about the ongoing work in progress. They had been clear and honest with staff about the areas for improvement.

Some staff told us they felt unsupported, and said frequent turnover of staff and managers had impacted on them. Staff were concerned about further changes. However, other feedback indicated there was an improving picture and the stability of the management team felt positive. A staff member commented, “The managers in place now arereally good, I can see how things have improved over the past couple of years.”

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

The provider had a whistleblowing policy in place, which staff knew about. The manager had an open-door policy and staff felt able to share issues. People and relatives also told us they felt able to approach managers if they had any concerns or feedback.

The provider valued diversity in their workforce. They were working towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider had an equality, diversity and human rights policy in place and staff undertook relevant training. They employed a diverse staff team and adopted an inclusive approach.

However, staff feedback was mixed, with some who felt the provider treated them fairly, but others who disagreed, especially in relation to certain employment conditions. The management team told us changes had been necessary to help support the required improvements. The home manager was dealing with staff concerns and aiming to build an improved working culture.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider had undertaken significant work, with governance systems and action plans in place to identify and address concerns. Under the current provider, the management team had initially been unstable, however, a new management team was now established and becoming more effective.

Despite improvements, governance systems had not always identified concerns relating to risk management, and we found examples where staff had not followed risk plans or where guidance was unclear. Records were not always accurate, complete, or up to date, which the provider acknowledged and was addressing through the introduction of digital systems and ongoing audits. Care plans sometimes contained inconsistent information, MCA assessments and best interest decisions were not always completed to a consistent standard, and reviews had not always identified or updated changes in people's needs. We found that whilst improvements were underway, systems and processes were not yet fully embedded.

Feedback from people and relatives indicated that improvements had been made at the home, with one relative commenting, “In the last three months, the home looks better, smells nicer, seems all together more organised.”

CQC notifications to inform us about certain incidents had been submitted as required.

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.

The management team worked in partnership with others such as the local authority and health professionals to share information. Feedback received from visiting professionals indicated they had a good working relationship with staff. They were working on an improvement action plan in liaison with others to learn and make required improvements.

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

The management team demonstrated they were focused on continuous learning at the home. They were open to our feedback and took some immediate actions in response.

The provider had won an award for the use of technology and Artificial Intelligence (AI) in dementia care. They were piloting “Wellbeing sensors,” which used technology to monitor people without using cameras, with the aim of enabling staff to respond to people more effectively. The provider held a quarterly committee meeting to consider any themes and trends across the organisation for assurance and learning purposes. They were launching a new platform to help support staff to access and understand the various polices in place.