Garsewednack Residential 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 inadequate. At this assessment, the rating has changed to 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 provider was previously in breach of the legal regulations in relation to safe care and treatment, consent and governance. Some improvements were found at this assessment; however, the provider was still in breach of the legal regulation relating to good governance.

The provider was no longer in breach of the legal regulations in relation to dignity and consent.

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 not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always fully understand the challenges and the needs of people and their communities.

The service did not always have a clear and shared direction or culture. Although some staff said morale had improved and they felt the service was “turning a corner”, key cultural expectations were still not consistently embedded. Staff told us they now felt more supported and listened to, but important aspects of the provider’s systems were not followed.

We found improvements required at the previous assessment had not all been acted on. For example, systems to identify and address risks were still not effective, and some concerns previously highlighted had not been resolved. Oversight arrangements put in place by the provider, such as daily walk‑arounds, were not fully implemented by the registered manager or used to drive improvement. This meant the culture did not consistently promote responsibility, openness, and continuous improvement.

Feedback from staff showed they wanted to deliver good care and believed the service was improving, but the lack of consistent follow‑through on required actions prevented a shared culture of safe, high‑quality care from being established.

Leaders did not have the skills, knowledge, experience and credibility to lead effectively.

Significant concerns remained from the previous assessment. Leaders had not addressed the improvements required, and key responsibilities were not being met. For example, assessments, audits and oversight processes were still not completed or monitored consistently.

Important safety checks, such as window restrictor audits and fire door monitoring, had stopped or were incomplete. Leaders had not ensured staff had up‑to‑date training, including in essential areas such as moving and handling, dementia and equality. Care plans lacked appropriate managerial oversight, and inaccuracies or omissions had not been identified by leaders.
Staff told us leaders were more approachable, but this was not supported by effective operational leadership or sustained improvements. The lack of decisive action meant the service still did not meet expected standards for leadership.

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

The service always encouraged staff to raise concerns and speak up, and staff told us they felt more able to share issues with the management team than they did previously. Staff described the registered manager as more approachable and responsive, and said communication had improved.

Staff understood how to raise safeguarding concerns and demonstrated awareness of their responsibilities to report risks. Incidents and accidents were being monitored, and staff described feeling listened to when they escalated issues.

However, while staff felt comfortable speaking up, systems for acting on concerns were not always reliable. Feedback from previous assessments had not consistently led to improvements, and some issues raised earlier, remained unresolved. Although the culture supported speaking up, the responsiveness to concerns was inconsistent and required further strengthening.

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.

The service always promoted equality, diversity and inclusion within its workforce. Staff had access to policies supporting fair treatment, and the service had an up‑to‑date equality and diversity policy. Staff told us they felt respected and treated fairly.

Staff described the service as becoming more inclusive and supportive, and we saw positive interactions between staff and people using the service.

While training in equality and diversity was missing for some staff, plans were in place to update this. The service had taken steps to improve culture and inclusion but needed to ensure all staff received appropriate training to maintain consistency.

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.

The service did not have effective governance or management arrangements. Systems and processes intended to ensure safe, high‑quality care were not operated effectively or consistently. Important audits had stopped, including fire door checks and mattress checks. Daily walk‑around processes were recorded but did not identify significant environmental and care‑related concerns found during the assessment.

Care records were inconsistent and lacked managerial review, resulting in gaps, outdated information and missing assessments. Issues previously highlighted in enforcement action—such as risks from windows, fire doors, burns, medication management and moving and handling—had not all been addressed. When we asked the registered manager about this, they said, “I need to develop something to check the care plans on a monthly basis. I need a system.”

Oversight between the provider and the registered manager was not effective, and improvements had not been sustained despite previous support and signposting to best practise guidance from the CQC and support from the local authority. Overall, the service lacked the robust governance required to ensure people’s safety and wellbeing.

This contributed to a breach relating to good governance.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The service did not always work effectively with external partners or local community services. Feedback from professionals was mixed, with some reporting concerns about responsiveness and partnership working. One professional said “Over the past few months the provider appears to have engaged more positively.” While improvements had been made in some areas, the service had not fully implemented actions requested by system partners, such as ensuring fire safety checks were maintained.

We saw examples of positive working relationships for people’s health, including regular GP involvement and engagement with the local authority quality team. However, information was not always shared appropriately or acted on in a timely way, limiting the effectiveness of some external partnerships. However, a health professional did tell us, “Information regarding residents relevant care and needs is always passed on to me in a professional manner.”
The service needed to improve how it collaborates with health and social care partners to ensure consistent standards of safety and quality.

We saw examples of positive working relationships for people’s health, including regular GP involvement and engagement with the local authority quality team. However, information was not always shared appropriately or acted on in a timely way, limiting the effectiveness of some external partnerships. However, a health professional did tell us, “Information regarding residents relevant care and needs is always passed on to me in a professional manner.”

The service needed to improve how it collaborates with health and social care partners to ensure consistent standards of safety and quality.

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.

The service did not have effective systems for learning or improvement. Opportunities to learn from incidents, feedback and audits were missed, and lessons learned sections were frequently left blank.

Enforcement actions from the previous assessment had not led to sustained improvements, and several concerns remained unchanged. Important learning tasks, such as understanding medication errors or updating care plans, had not been completed.

Some improvements were noted by staff, but these were not supported by structured learning processes. There was limited evidence of innovation or proactive improvement. The service still needed to develop reliable systems to learn, adapt and prevent repeated issues.

The provider and registered manager did not always focus on continuous learning, innovation, and improvement across the organisation. The provider did not always monitor progress and take appropriate action without delay where progress was not achieved. This meant there was a continued breach of regulation relating to good governance.