Scarlet 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 good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 86 (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 registered manager consistently led by example through mentoring his team and leading with a clear vision and culture. The registered manager drove organisational values to ensure people were supported with equity, diversity and inclusion, positive engagement and consistent delivery of high-quality care and support.

Staff told us the registered manager and deputy manager worked extremely well as a team.

The management team shared with us a great deal of very positive feedback about their leadership style and approach. The registered manager and the deputy manager knew the people who lived in the service and the staff team incredibly well. This awareness allowed for people’s needs and challenges to be fully assessed and needs to have been consistently met. We were told people, relatives and staff alike had tremendous confidence in the management team. Such feedback included, “He's [registered manager] a walker, he's everywhere! If you're busy with an emergency either him or the deputy manager will help out with medicines, or call bells, whatever you need” and “He’s so approachable and he really listens, so compassionate.”

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.

People and their relatives told us they knew who the registered manager was and the service was managed by capable, transparent and compassionate leaders. People told us, “I see the [registered] manager and the deputy a lot. They are very nice.”
Staff told us the service was managed by leaders who had the skills and experience to lead them effectively. A member of staff told us, “The managers are lovely, [registered manager] and [deputy manager] are fantastic, they are always around, you can go to them about anything.”
The registered manager demonstrated an in-depth understanding of all areas of the service, including people’s needs and any challenges.
The registered manager acted on any areas of improvement which were highlighted by actively seeking feedback, and by recognising their own areas of development.

Scarlet House had two trained Mental Health First Aiders who offered confidential support and held drop-in sessions for colleagues requiring help or advice. A staff-room information board displayed their photographs, contact details and other useful support numbers.

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

Staff and leaders acted with openness, honesty, and transparency. Staff told us, “I have had to report other staff for certain things I saw in the past and the [registered manager] was very approachable and my concerns were addressed.” Staff had access to the whistleblowing policy and there were posters in the staff room with contact details of other organisations. The provider conducted regular surveys which were benchmarked against other services in the organisation. The results for the service showed a high response rate with staff agreement they felt confident raising concerns and speaking freely. There was a culture of integrity which ran through all the staff teams.

Staff had training in whistleblowing during their induction and received a subsequent knowledge check to ensure understanding. Training was given to all staff on a regular basis.

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.

Checking accountability included an ongoing review of policies and procedures by the registered manager and provider to tackle structural and institutional discrimination and bias to achieve a fair culture for all. Staff told us they felt the service treated everyone equally and did not disclose any concerns.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver high-quality, sustainable care, treatment and support. They always acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Leaders demonstrated exceptional oversight and forward planning, ensuring the service was resilient, adaptable and consistently delivering high-quality care. Improvements were not only achieved but sustained over time, with clear evidence of positive outcomes for people. The service had achieved numerous accolades over the past several years. Earlier this year a unit manager won an award for dementia care at the UK Dementia Care Awards.

The registered manager demonstrated governance, management and sustainability were a clear strength of the service and made a significant contribution to the consistently high standards experienced by people.

Leaders drew on multiple sources of information, including audit findings, feedback, and outcomes, to inform strategic decision-making and enhance care delivery. Action plans were developed by the registered manager to identify areas for improvement and were addressed within agreed timescales. Governance arrangements went beyond routine checks and were used proactively to identify trends, anticipate risks and drive continuous improvement.

The provider had a strong commitment to quality assurance, and the provider had a dedicated staff member who would visit the service regularly to complete audits and mock inspections. We found these to be detailed, informative and drove improvements in the service. These audits not only contained statements for every section, not just tick boxes, but also contained before and after pictures. These audits were of a very high standard.

Investigation reports for serious incidents were completed titled ‘Safety Incident Investigation Reports’ and were in-depth case studies which included detailed analysis of incidents and were used to improve the quality-of-care people received.

There was a strong, service‑wide culture of ownership and accountability, with staff at all levels actively engaged in quality assurance and improvement activities. Learning from incidents, complaints and feedback was shared openly and used to make sustained and meaningful improvements. Staff were actively consulted and involved in making improvements to the service provided. Examples included care planning, daily routines and training.

Staff received high quality supervision, appraisal and ongoing training which strengthened skills and maintained safe practice. Without exception, all staff were very positive about the training and support they received.

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.

External professionals told us the service worked well with them and listened to feedback. Staff effectively shared information with others in healthcare and within the local community. The registered manager worked collaboratively with partners and care records showed external professionals were involved in people's care. One external professional told us, “The service is very good at referring in a timely manner. Sometimes we get multiple referrals in a day which is good as it shows they refer things as they find it.”

The service had multiple events and activities which were advertised to the general public and were well attended. Some events even had waiting lists. The registered manager wanted to promote the service as a part of the community, and not a place which was off limits.

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. They actively contributed to safe, effective practice and research.

The service demonstrated clear evidence feedback and reflection led to measurable improvements in people’s care.

The registered manager and deputy manager, alongside the unit managers, kept up to date with new innovations in the care sector, for example, 1 unit manager was planning on holding a falls prevention event where they would discuss new ways of preventing falls in older people. This was an event which would be open to the general public and other services.

People were meaningfully involved in service development. Alongside regular resident and relative meetings, people were supported by the wellbeing team to give feedback on meals, activities and how they felt during the day. There was a strong emphasis on improving people’s mental health.

The service demonstrated strong, sustained least restrictive practice. People were supported to live freely which reflected the skilled, proactive and preventative staff responses and a culture focused on dignity and understanding behaviour. The use of PRN (as required) medication for supporting people who had anxiety or distress was very low.

Learning from incidents, feedback and audits was embedded and shared across the team by the managers, ensuring continuous improvement. As a result, the service delivered highly responsive, innovative and person-centred care, with clear improvements in people’s engagement, independence quality of life and outcomes.