The Callywhite 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. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good.

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 75 (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 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.

There was evidence of a focus on learning and continuous improvement. The provider had commissioned an external audit of the service to obtain independent feedback on quality and performance. Following the audit, an action plan was developed, and improvements were progressed to address identified areas for development. This demonstrated leaders were proactive in seeking assurance and committed to driving ongoing improvements.

The provider also held monthly management and clinical governance meetings. These meetings provided opportunities to review service performance, share important information, discuss key learning and identify actions required to maintain and improve standards of care. Records showed actions identified through these meetings were followed up and completed by the registered manager, demonstrating accountability and a commitment to continuous improvement.

Leaders promoted a compassionate and approachable culture that encouraged trust and open communication. The registered manager was visible within the service and maintained a strong presence among people, staff and visitors. Their office was located close to the communal areas, enabling them to remain accessible and available throughout the day.

Our observations indicated people, relatives and staff were comfortable approaching the registered manager.
 

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.

The leadership team's presence within the home enabled them to maintain oversight of the quality of care being delivered and build positive relationships with people, relatives and staff.

Staff told us they felt well supported by the registered manager. They were confident that any concerns relating to their wellbeing would be listened to and acted upon appropriately.

The registered manager and leadership team demonstrated a good understanding of their regulatory responsibilities and the expectations of the Care Quality Commission (CQC). They were able to discuss current requirements and recommendations and explained how they kept themselves informed of relevant changes within the health and social care sector. This helped ensure the service remained compliant with best practice guidance and regulatory expectations.

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

There were a variety of opportunities for staff to raise ideas, concerns and suggestions, including through staff surveys, supervision sessions and team meetings.

Records demonstrated that staff were regularly asked for their views and were actively involved in discussions about the development of the service. Staff told us feedback gathered through surveys and meetings was shared with them.

The provider adopted a proactive approach to acting on feedback through the use of action plans and a, 'You said, we did approach.’ This demonstrated leaders listened to staff and took meaningful action in response to concerns, suggestions and opportunities for improvement.

Staff described feeling comfortable raising concerns and were confident they would be listened to by the management team. Processes were in place to ensure concerns were handled sensitively and confidentially. Where issues were identified, leaders investigated appropriately, shared lessons learned and implemented actions to reduce the risk of similar issues occurring in the future.
 

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 spoke positively about the culture within the service and told us they had never witnessed discrimination. This demonstrated a workplace culture where equality, diversity and inclusion were respected and where staff felt able to work alongside colleagues from a range of backgrounds and experiences.

The provider recognised the importance of supporting staff wellbeing and ensuring staff had access to appropriate support both within and outside of the workplace. A staff perks programme was available which included access to a 24-hour GP service, counselling support, retail discounts and a range of other benefits. These initiatives helped to promote staff wellbeing, reduce potential barriers to accessing support and demonstrated the provider's commitment to valuing and supporting its workforce.
 

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 operated a comprehensive programme of governance activities, including monthly audits, staff observations and regular meetings involving all departments, such as, housekeeping and maintenance. This helped ensure all aspects of service delivery were reviewed and that concerns or areas for development were identified and addressed promptly.

The provider maintained strong oversight of the home through access to live documentation and performance information. An action plan was in place to monitor progress against identified improvements, supported by a traffic light system which clearly highlighted priorities and deadlines.

There were also arrangements in place to provide independent oversight and encourage shared learning across services. Registered managers from other locations regularly visited and audited each other's services, providing an external perspective and helping to identify opportunities for improvement that may not otherwise have been recognised.

Systems were in place to ensure appropriate external agencies and partners were notified when required, including following incidents, accidents and safeguarding concerns. This helped ensure people remained protected and that information was shared appropriately with relevant organisations to support accountability, learning and effective partnership working.
 

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.

Leaders recognised the importance of partnership working in promoting positive outcomes for people and ensuring they had timely access to specialist advice and services when required. The registered manager maintained oversight of people's needs and referrals made to external professionals. Systems were in place to identify when additional support or specialist input was required, and appropriate referrals were made promptly. This included working closely with district nurses, local NHS services, dietitians and other healthcare professionals to ensure people's health and wellbeing needs were met.

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.

Leaders encouraged staff to contribute ideas and suggestions about how the service could be improved, helping to create a culture where learning and innovation were valued. Staff were given opportunities to share feedback and identify areas for development, supporting a collaborative approach to service improvement.

Robust quality assurance systems were in place to monitor the quality and safety of care provided. Audits, oversight processes and action plans were used effectively to identify areas for improvement and track progress against required actions.

The registered manager demonstrated a commitment to learning from wider sector developments and best practice. They told us they attended local forums whenever possible, which provided opportunities to share learning, gain insight from other professionals and keep up to date with emerging guidance and developments within health and social care.