Carisbrooke 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.

This is the first assessment for this service. 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 regulation in relation to good governance.

This service scored 57 (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 did not yet demonstrate a clear and well‑embedded shared vision, strategy or culture based on transparency, equity, equality, human rights, diversity and inclusion, and ongoing engagement. Although some elements of a positive culture were present, these were not consistently translated into practice.

Staff told us they were committed to delivering dignified, person‑centred care and described approaches that placed people at the centre of decisions about their lives. They demonstrated values aligned with supporting people in ways that suited their individual needs and preferences. This showed staff were working with good intentions and a genuine desire to promote people’s dignity, comfort and wellbeing.

However, oversight and quality checks had not effectively identified or mitigated several issues found during the assessment. This meant leaders had not consistently directed staff or aligned day‑to‑day practice with the shared values they aimed to promote.

Staff told us that management were approachable, supportive and available to discuss ideas and concerns. This demonstrated that positive working relationships existed, and that staff felt able to contribute their thoughts to the running of the service. This supportive atmosphere was a strength; however, it was not accompanied by a structured, strategic framework to channel this culture into measurable, sustainable improvements.

While the registered manager was passionate about providing person‑centred and individualised care, there was no clear or detailed strategy that described how this vision would be achieved. This included a lack of planned steps, measurable goals or systems to ensure regulatory requirements were consistently met. Without a clear strategic direction, the service could not be assured that improvements would be consistently embedded or maintained over time.

This feedback was shared with the provider who told us they would take action to ensure that a strong direction and culture were embedded.

The service benefited from capable, compassionate and dedicated leadership. The registered manager demonstrated a commitment to the service and was knowledgeable about the needs of the people living there. During the assessment, the registered manager responded openly and promptly to questions, showing a clear understanding of the service.

Staff told us they worked well together as a team and communicated effectively, particularly during handover meetings where important information was shared.

Leaders were described by staff as approachable and supportive. Staff had no concerns about raising issues and felt confident that leaders would listen and respond appropriately. People who used the service, staff and external professionals were all complimentary about the leadership. One external professional commented that leaders went, “above and beyond,” reflecting the positive relationships and responsive approach taken by the management team.

Staff spoke highly of the registered manager, describing them as kind, supportive and always available. They felt valued and supported in their roles.

Although there had been some recent changes in leadership, the registered manager ensured that new team members were supported to become familiar with the service and the local community. This helped maintain stability and continuity for people using the service. The provider also supported staff development and career progression, which contributed to staff retention.

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

Staff were aware of freedom to speak up and told us they felt able to speak up if needed. They were confident concerns would be dealt with and had trust in the management.

The provider had a whistleblowing policy in place to support staff in this process.

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.

Leaders made reasonable adjustments to support staff with physical or psychological difficulties. The registered manager explained how they would have regular check-in’s with staff and were provided with debriefs if there had been an incident.

Staff told us how leaders and staff treated everyone equally within the care home.

The manager was able to explain the process of supporting staff when they raised concerns and how processes had been followed to investigate and address these.

All staff members we spoke with stated they felt they were treated equally and supported fairly. Staff were aware of policies and procedures and had received training around equality and diversity.

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

Although some audits and governance checks had been completed around medicines, infection control and care plans for example, these did not provide a comprehensive overview of the quality and safety of the service. This meant that audit processes were ineffective and did not drive improvement.

Some records were repetitive for staff to complete, while others contained insufficient detail or conflicting information. We found records of people’s care and incident reports were often lacking in detail, making it difficult to understand what had occurred or whether appropriate actions had been taken.

These discrepancies had not been identified or addressed by the manager, which demonstrated a lack of oversight in key governance functions.

The registered manager told us they previously reviewed incident reports but were no longer able to do so due to the increased number of incidents as the service had grown. This meant there was no effective system to ensure the quality of incident reporting, identify themes or trends, or ensure lessons learned were embedded into practice. As a result, opportunities to reduce risks and improve safety were missed. This meant that audit processes were ineffective and did not drive improvement.

While the provider did respond when concerns were raised, they did not have robust, proactive systems to routinely monitor, review or improve care. This reactive approach meant that issues were addressed only after problems had been identified by others, rather than through effective internal oversight.

Staff rotas showed that some staff regularly worked long hours without scheduled breaks. There were no risk assessments in place to evaluate or mitigate any risks associated with fatigue or reduced competence due to extended working hours. When this was raised with the provider, they acknowledged the concern and stated they would review the systems in place to improve safety; however, this highlighted further gaps in governance and workforce management.

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 leaders were open and transparent, and they collaborated with all relevant external stakeholders and agencies. Partners were complimentary about the service.

People were supported by staff and the management team to engage with their local communities and partners. This included GP’s, and others involved in their care and support.

The provider did not focus on continuous learning, improvement or innovation across the organisation.

Leaders did not always demonstrate a clear understanding of how to drive improvement within the service. Although staff were committed to provide good care, the systems needed to support meaningful learning and development were not embedded. This limited the provider’s ability to make sustained improvements or ensure that good practice was consistently applied.

Feedback from staff, people using the service and their relatives was not regularly gathered. This meant leaders lacked essential insight into people’s experiences and did not have a comprehensive understanding of where improvements were needed.

The provider did not carry out effective reviews of incidents or accidents. There were no thematic reviews in place, meaning that recurring patterns, risks or learning opportunities were not identified or shared. Without these processes, the service could not reliably recognise trends or implement changes to prevent similar incidents from happening again.

This lack of effective learning and oversight placed people at risk of avoidable harm, as leaders could not be assured that people’s needs were consistently met in a safe and well‑managed residential environment. This meant the learning and improvement processes were ineffective.