Carrstone House 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. This key question has been rated as 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 governance at the service.

This service scored 43 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, and engagement. However, they did not always understand the challenges and the needs of people and their communities or follow their own vision and culture.

Shortfalls identified within this inspection in relation to delayed referrals and medical attention did not demonstrate a culture which had a joined-up approach.

We viewed resident meeting minutes which had been held in July 2026 which included that 1 person had requested smaller cutlery as they found it difficult to hold. The resident meeting minutes held in August 2026 included "during our last meeting the issue of cutlery was raised, we are not yet in the position to be changing that now."

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Feedback from staff included concerns about staff morale and lack of supervisions. They also raised concerns about feeling able to speak up freely. The service had not had a registered manager since October 2025; the provider had been actively recruiting for this position. An interim manager had been appointed, and the regional management team had also provided support to the service when needed, however, staff reported that the lack of a consistent manager had affected the running of the service, and the support staff had received.

People did not always feel they could speak up and that their voice would be heard.

Staff did not receive regular supervisions; staff meetings were regularly held. Feedback from staff included, " Feel there is a bit of a culture of fear. Should be more culture where the management support you. People are a little bit scared." Staff also raised concerns with confidentiality, where personal issues had been shared amongst the staff without their knowledge.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them. Not all staff said they felt valued by the provider, Feedback included, "Could do with having staff’s back more", while another staff member said, " the regional managers have been supportive while we haven't had a manager."

The provider had a staff reward scheme in place and staff had received equality and diversity training.

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.

There had been a lack of consist management oversight since October 2025. While auditing systems were in place they had not always identified the concerns found during our inspection.

There was not a clear process for monitoring the quality of information on daily care records. Care plans and risk assessments were not always updated in a timely manner when people's needs changed and discrepancies had not been identified.

The service had appointed a new manager the week before the inspection commenced and staff, people and relatives hoped having a consistent manager would improve the quality of care provided. However, the impact of the new manager could not yet be assessed.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement. Care plans and risk assessments were not always up to date and held discrepancies. Referrals to health professionals were not always made in a timely manner and records relating to visits from health professionals were not aways recorded or detailed.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research. Auditing systems to monitor daily care notes, repositioning records and food intake were not in place. This meant that opportunities to improve the quality of care provided. Auditing systems which were in place had not always identified all concerns, where concerns had been identified actions had not always been taken to rectify these concerns.

Concerns found at this inspection had not always been identified by the service through their auditing processes.

Where concerns were raised to the provider during the inspection action had been taken to rectify these.