Charterhouse 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 good. At this assessment the rating has changed to 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 demonstrated a clear shared vision, strategy, and culture based on transparency, equity, equality, human rights, diversity, inclusion, and engagement. Leaders showed a strong understanding of the challenges faced by people and their communities, and how to meet their needs effectively.

Leaders told us their approach aligned with The Council of St Monica Trust’s “3 Cs”: Connection, Contribution, and Choice. We saw evidence of how these values were embedded in practice, including through staff and people meetings and wider engagement activities. For example, family events, such as family teas, encouraged meaningful interaction, providing opportunities for people to spend time with relatives, including children and grandchildren.

Professionals spoke positively about the service; with one stating there was a genuine desire and commitment to continually improve outcomes for people. Another professional commented that the home was well run and provided a pleasant environment where people appeared happy and settled.

Staff also described a positive culture, with one stating, “The Charterhouse vibe is positive, and the people around are caring, with a desire to learn and share experiences.”

This meant there was a strong, values-led culture across the service, which supported positive relationships, meaningful engagement, and high-quality care for people.

The provider demonstrated exceptionally inclusive leadership at all levels. Leaders had a clear understanding of the context in which they delivered care and consistently embodied the organisation’s values, acting with integrity, openness, and honesty. They demonstrated the skills, experience, and credibility required to lead effectively and inspire confidence among staff, people, and partners.

Leadership was strengthened by well-established and inclusive recruitment processes and effective succession planning. A clear organisational structure, with well-defined roles and responsibilities, was supported by a strong focus on staff development, training, and career progression. Leaders actively promoted a culture of continuous learning and improvement.

Senior leaders spoke highly of the registered manager and their team, recognising their commitment to developing others and creating opportunities for growth. This included access to training programmes, workshops, and apprenticeship pathways from level 2 through to level 7. A structured mentoring programme further supported new and developing staff, ensuring knowledge and best practice were consistently shared.

Staff described leadership as approachable, supportive, and empowering, with one noting the team was “excellent” and “outstanding.” Professionals also spoke positively about the service, highlighting the professionalism and compassionate approach demonstrated by leaders and staff. Relatives described leadership as visible, engaged, and highly effective, noting leaders remained accessible and maintained high standards.

This strong and inclusive leadership approach created a positive organisational culture where staff felt valued, supported, and confident in their roles.

The provider promoted a positive and open culture, where people felt confident to speak up and were assured their views would be listened to and valued.

Effective systems were in place to enable people, relatives, and staff to raise concerns or share ideas. We saw several examples where feedback had been acted upon, leading to meaningful changes and improvements. A whistleblowing policy supported staff in raising concerns appropriately.

Staff told us they felt comfortable speaking up and had regular opportunities to do so through an open-door culture, supervision, reflective practice, and team meetings.

We observed that management and senior leaders were visible and approachable throughout the home, engaging with staff in a respectful and supportive manner. Staff were aware of how to raise concerns externally if needed; however, they told us they felt confident raising issues with managers and senior leaders.

The provider valued diversity within their workforce and actively promoted an inclusive and fair culture, improving equality and equity for staff.

Staff described the manager as a key driver of continuous learning and career development. They told us they felt well supported by managers to achieve positive outcomes and navigate challenges in their roles. The provider’s commitment to supporting all staff, including those who were neurodivergent or living with disabilities, was well recognised and embedded in practice.

Leaders promoted inclusion by supporting neurodiverse staff, providing targeted training, and making reasonable adjustments to systems to ensure information was accessible and easily shared. They also demonstrated a strong commitment to developing the future workforce through placements, work experience, and opportunities for those considering a career in health and social care. This was further supported by apprenticeship roadshows, partnership working with the local health trust, and well-established links with local colleges, helping to reduce barriers to entry and support career progression.

The provider took a proactive and personalised approach to inclusion, making thoughtful adjustments to support staff during Ramadan and throughout pregnancy. Leaders demonstrated a clear understanding of individual needs, ensuring support was respectful, inclusive, and responsive to staff’s cultural and health requirements.

The provider demonstrated clear roles, responsibilities, and systems of accountability, supported by effective governance arrangements. These were used to monitor, manage, and deliver high-quality, sustainable care, treatment, and support. Decisions were based on appropriate information relating to risk, performance, and outcomes, which was shared securely where necessary.

Clear accountability structures were in place, with defined roles and responsibilities. A programme of audits was completed by leaders,with additional oversight from the registered manager and senior leadership team. This included regular audits of key areas such as falls, call bells, and equipment to ensure safety and effectiveness.

Records and associated action plans identified areas for improvement, and we saw evidence that appropriate action had been taken to address identified shortfalls and drive improvement. Systems and processes were effective in promoting continuous oversight and quality assurance. Regular meetings were held to review governance arrangements, performance, and the overall quality of the service.

The provider demonstrated a well-established and proactive approach to partnership working, with a clear understanding of their role within the wider system to ensure seamless, person-centred care. Effective systems were in place to share information, learning, and best practice with partner organisations, supporting continuous improvement and positive outcomes for people.

The provider actively sought, listened to, and acted on feedback from external professionals to enhance service delivery. Feedback from partners was consistently positive and reflected strong, collaborative relationships. One professional told us, “The atmosphere is always positive, and I am welcomed by staff and managers. Managers and house leads are approachable and consistently helpful with any questions.” This demonstrated a culture of openness, professionalism, and mutual respect.

The provider showed a strong commitment to social responsibility and community engagement. They led and supported initiatives that benefited the wider community, including an inclusive gardening project accessible to people of all ages. In response to the cost-of-living crisis, the service implemented a community fridge, enabling surplus food to be shared locally. This demonstrated a proactive and compassionate response to emerging community needs.

The service had developed meaningful and sustainable partnerships within the local community, including close working relationships with schools and childcare providers. This supported intergenerational engagement, creating opportunities for people using the service to build relationships with younger members of the community. These interactions promoted mutual understanding, reduced social isolation, and enhanced wellbeing for both groups.

The provider demonstrated an exceptional and deeply embedded culture of continuous learning, innovation, and improvement across the organisation and wider system. There was a clear, proactive, and sustained commitment to developing creative and forward-thinking approaches that promoted equality of experience, improved outcomes, and enhanced quality of life for people using the service. The provider not only responded effectively to change but actively drove improvement through meaningful engagement in research and innovation, contributing to the development of safe, effective, and progressive practice.

A key example of this was the role of the innovation manager, who worked directly with people to identify opportunities for improvement and co-develop solutions. The provider collaborated with research and innovation organisations to design and implement advanced assistive technologies. These included digital gait assessment to support mobility and independence, AI-enabled smart socks to monitor vital signs and movement, and sleep analysers to track sleep quality and detect potential health conditions. All initiatives were underpinned by a strong focus on enabling people to flourish and achieve the best possible outcomes.

Co-production was fully embedded within the service, with people actively involved in shaping and developing care through engagement and trials. Evidence was seen of people participating in these activities, including photographic records of involvement. This inclusive approach empowered individuals, strengthened independence, fostered a sense of belonging, and reduced social isolation.

Technology further enhanced monitoring and responsiveness. For example, acoustic monitoring systems enabled staff to respond promptly to people’s needs without the need for intrusive night-time checks. This non-intrusive approach protected people’s dignity, reduced unnecessary disturbance, and supported improved sleep quality and overall health and wellbeing.

Staff consistently described highly positive learning and development opportunities. Structured pathways for aspiring and emerging leaders were supported through mentoring, coaching, and tailored leadership programmes. Staff reported increased confidence, skills, and career progression as a result, contributing to effective succession planning and a sustainable leadership culture.