Cuttlebrook Hall

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 newly registered service. This key question has been rated 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.

The provider had a clear focus on delivering high quality care and was strongly committed to empowering people and promoting their independence. They spoke passionately about ensuring people continued to feel as though they were living in their own home. This approach underpinned the provider’s vision for person centred care and created an environment where people’s autonomy, comfort and individuality were prioritised.

Leaders worked with people and their relatives to build a culture that focused on enabling people to enjoy their lives and achieve their personal goals. For example, the provider had introduced a wish tree, where people could write down their wishes, and staff worked collaboratively to help make these wishes come true. We saw evidence of wishes being fulfilled, including themed days arranged in response to people’s interests and people being supported to improve their mobility so they could walk independently. One person was supported to visit a relative who did not live locally, staff assisted them to book a table for lunch, which the person was overjoyed about, as they felt they were able to do something for their relative rather than the other way round. This demonstrated a highly personalised approach that celebrated what was important to people and promoted meaningful, positive experiences.

Staff consistently knew people well, and promoted independence, choice, and support in the least restrictive way.

The service had an extremely positive culture, which was demonstrated by staff and management. Staff consistently told us they enjoyed working at the home. Comments included, “It’s great I love my job and I don’t believe there is much else I would ever want to do. Sometimes working weekends and long hours can be a lot, however this is healthcare and that is part of the job, I love my job,” and “I’m really proud of the work I do, I make people smile everyday. That’s what makes my job, I make them comfortable and I make them smile, they’re happy.”

The provider demonstrated a positive listening culture by acting on feedback they had received and informing and updating people of any changes they made because of this.People and their relatives were consistently positive about their experiences of the provider and how the management and staff team were approachable and how they had developed positive relationships with them.

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 we spoke with were consistently highly complimentary of the registered manager. One staff member told us, “[Manager] is a really good manager, [manager] is approachable and respectful to all staff.” There was a clear culture of continuous learning, improvement and delivering person centred care in the least restrictive way. The registered manager had the skills, knowledge and credibility required to lead the service effectively. They demonstrated integrity, openness and honesty in their approach, which helped create a positive culture where staff felt supported and people received high‑quality care. One person told us, “I like [registered manager], they are lovely and to me they know how to do things”.

The management team, including the deputy manager and team leaders, were visible to both people and staff and led by example. Staff spoke positively about the management team. Comments included, “[Manager] is a really good manager, they are approachable and respectful to all staff,” and “I am already on an apprenticeship. I can spend time with supervisors as much as possible to learn new things and if I ever have a question, I am always supported to find the answer.”

The management team spoke about staff in a positive and compassionate way, demonstrating genuine appreciation for their contribution. Comments included, “It’s a good place to work. I have learnt a lot being [job role] and have learnt a lot from my manager about ways to improve. I enjoy interacting with residents and families and making a positive difference to their lives. I enjoy supporting my team,” and “We have such a lovely team who are understanding and approachable. I find they are happy to work and appreciate their jobs. They are excellent at what they do, and I like to ensure, as [job role] I say thank you for a lovely shift each day.” This reflected a positive culture of mutual respect, recognition and strong team morale.

This outstanding leadership fostered a culture of openness, trust and respect, where people, families and staff felt valued, supported and empowered. The visible presence of themanagement team, together with their commitment to delivering person centred care, ensured the home was not only well led but also a warm, inclusive and welcoming place for everyone.

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

The provider had a designated mental health first aider and a colleague’s voice champion in place. The colleague’s voice champion was a staff member who staff could speak to confidentially, and who would raise concerns on their behalf in a discreet and supportive manner. This helped promote an open culture where staff felt listened to and able to share issues safely.

Staff told us they felt comfortable raising concerns, and when they did so, they felt listened to. One staff member told us, “I can speak to [registered manager] or [deputy manager], theymake timefor us to approach them. They are open to listen to what we say. My supervisors also supportme. I am never dismissed or made to feel what I have to sayisn’timportant.” Another told us, “I do feel I can raise concerns with my manager, I do feel listened to when I bring things into team meetings. We always go around the group and manager does ask if we as individuals have anything to add.”

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.

Staff told us they felt valued and respected by both the provider and the manager, they felt supported to give feedback and were treated equally, free from bullying or harassment.

The provider had a policy in place to ensure staff were treated fairly and had equal opportunities to learn and develop their roles within the organisation. There were fair recruitment processes in place, which helped to protect the rights of staff under the Equality Act.

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.

The provider had various audits in place to ensure they maintained strong oversight of the service. These included a quality performance report reviewing key areas such as falls and skin breakdown risk, a monthly falls analysis, and a call bell audit which reviewed call bell response times. There was also an enhancing mealtimes audit that focused on the dining experience, and a documentation audit to check the accuracy and completeness of records. For example, one audit identified a staff member had failed their falls awareness training, enabling prompt action to be taken. Any actions identified through these audits were addressed without delay. Feedback provided to the registered manager during the inspection was also acted upon quickly, demonstrating their responsiveness and commitment to continuous improvement.

The registered manager had strong oversight of documentation. Files and records were stored securely due to a robust filing system, and folders were kept up to date. Documentation was well organised and easy to access during the inspection.

The provider clearly understood and carried out their duty to collaborate and worked in partnership, and services worked seamlessly for people. They always shared information and learning with partners and collaborated for improvement.

The provider had developed a wide range of initiatives to strengthen community connections and promote social inclusion. Activities included a menopause awareness talk, a men’s club that offered opportunities for gentlemen to socialise with others from the local community, and a weekly knit and natter group. People in the local community were invited to join the knit and natter sessions, enabling individuals to share skills, meet new people and build friendships. A memory café was held twice a month and was open to people in the local community and their relatives. This provided a supportive space for people to socialise with others in similar situations and reduced the risk of social isolation.

The provider also worked in partnership with specialist community groups. An aphasia support group took place twice a month and was open to the wider community, creating valuable opportunities for support and advice. The provider had also hosted an understanding dementia event, with another scheduled, which aimed to support people living locally and their families to learn more about dementia. These initiatives demonstrated a strong commitment to community involvement, partnership working and supporting people to maintain meaningful connections.

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, outcome and quality of life for people.

The provider had an exceptional culture of learning, where opportunities for continuous improvement were actively sought. Each accident or incident was subject to detailed analysis, and a root cause analysis was completed to determine the cause of the incident and whether the person’s needs had changed. This approach ensured the service continually learned from events, identified emerging risks and made informed decisions to improve the quality and safety of care. This was demonstrated by the provider when a person with a life limiting medical condition and dementia moved into the home following a bereavement, the management team and staff acted proactively to understand their needs and promote independence. On admission, the person required support to eat their meals and did not engage with social activities. The team worked closely with external professionals, including adapting the person’s medication routine in line with specialist advice and introducing a structured medication tracker to support smaller, more frequent doses. Weekly meetings took place with external health professionals, and staff worked with the person and their relatives to develop a personalised activity plan tailored to the person’s interests. Leaders also delivered bespoke bereavement training based on learning from past experiences within the home, helping staff understand how to support people during a bereavement. Over time, the person’s abilities improved, they regained independence with eating and now join in with activities.

Governance systems ensured that accidents and incidents had lessons learnt completed, and these were shared with staff in a variety of ways such as incident bulletins and in team meetings. The registered manager told us that, in addition to completing formal lessons learnt documents, they held as and when needed huddle meetings to discuss learning from incidents. Staff supervisions were also used as an opportunity to reflect on incidents that had occurred and consider what could be done differently. This approach supported a strong learning culture where staff were encouraged to reflect on practice, share insights and continuously improve the quality and safety of care.

Training had been developed in response to incidents that had occurred, ensuring staff were able to learn from them and strengthen their ways of working.