Caraston Hall

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 remained 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.

Staff understood the provider’s aims and objectives, which were “to provide safe, quality care, support and housing that creates an environment which promotes recovery and enables individuals with complex mental health problems and learning disabilities to thrive.” The culture of the service reflected these values, with people being empowered to take control of their lives. Staff were clear about organisational expectations and understood the importance of treating everyone with dignity, respect, fairness, and equality.

The registered manager told us they promoted an open and honest culture. Information was shared effectively with staff through daily handovers and regular team meetings.

Systems and processes were in place to ensure staff were well supported and equipped with the skills and knowledge needed to maintain a positive culture within the service. Staff described a supportive working environment where their contributions were recognised and valued by the senior management team.

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 registered manager promoted an open culture where staff felt valued, listened to, and supported. One staff member said, “[Registered manager name] is amazing. I love working here, and that’s down to the manager.”

People and their relatives had confidence in the registered manager and told us the service was well managed. One relative commented, “The service is managed very well.”

The registered manager led by example and was visible, responsive, and actively involved in care delivery. Throughout the assessment, they demonstrated a strong knowledge of the people living at the service. It was evident that the service was providing quality, person‑centred care.

The registered manager had established effective links with key organisations providing social care services to improve people’s opportunities and experiences. For example, they worked alongside Harbour Drug and Alcohol Service to help ensure people had access to appropriate support. Healthcare professionals expressed confidence in the service and the management team.

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

People and their loved ones were aware of how to make a complaint and felt comfortable raising concerns if something was not right. One person told us they would speak to the manager if they were unhappy. Relatives also expressed confidence in the management team to respond to any issues raised. One relative said, “Whenever we have any concerns, I contact [registered manager’s name]. She is always very helpful and attentive to us in every matter.”

The provider had policies in place to support staff to speak up, raise concerns, and keep people safe. Staff spoke positively about the registered manager and deputy managers, telling us they felt able to raise concerns if needed. One staff member said, “I can speak with either manager; they are both very supportive and listen.” Another said, “[Managing Director’s name] and [Registered manager name] are very approachable and will make time if you want or need to speak with them.”

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 registered manager told us the service did not tolerate bullying, harassment, or discrimination. The staff team was diverse, with a mix of genders, ethnicities, and backgrounds. The registered manager demonstrated an understanding of their legal responsibilities under the Equality Act 2010, including the duty to make reasonable adjustments for staff, and gave an example of how they had tailored employment arrangements to meet a staff member’s specific needs.

The registered manager also recognised the value of recruiting international staff and the positive impact this had on the cultural diversity of the service. The service promoted an open, transparent, and inclusive culture in which staff felt welcomed and accepted, underpinned by appropriate policies and procedures.

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 had strong and effective governance systems in place. A regular programme of audits was carried out to assess all aspects of the safety and quality of the service and to identify any issues. These quality assurance and governance processes helped monitor management and leadership, as well as the ongoing quality and safety of the care people received. Where shortfalls were identified, action was taken.

There were clear lines of responsibility and accountability within the management structure, which helped ensure staff at the right level made decisions about the day-to-day running of the service. The registered manager was aware of their responsibilities under the duty of candour, which requires providers to be open and honest about any accident or incident that has caused, or placed a person at risk of harm. They had notified the Care Quality Commission of all significant events in line with their legal obligations.

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.

The registered manager recognised the importance of working in partnership to improve people’s outcomes. They described how they worked closely with people, their families where appropriate, and the local authority to support positive outcomes. The service had developed effective working relationships with professionals, including the Community Forensic Team, the Specialist Outreach Recovery Team, and Community Mental Health Teams. These partnerships enabled timely referrals and the effective sharing of information, which supported consistent and coordinated care.

In addition, Devon Partnership Trust and Livewell Southwest provided bespoke training delivered by specialist trainers. This supported staff to better understand and meet the needs of the people they cared for and promoted ongoing staff development and competence.

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.

The registered manager described how they used all available information to identify learning, embed good practice, and drive improvement. They maintained regular communication with the provider, people, relatives, and staff to share feedback and best‑practice guidance, helping to ensure the service remained safe and effective.

The provider had introduced a Creative Solutions Forum. The Forum offers a structured platform for staff to collaboratively explore and address complex, primarily clinical, scenarios related to the care and support of people using the service. Through creative, collaborative, and solution‑focused discussion, the Forum aims to strengthen risk‑sharing practices and enhance risk management and safety strategies.

The registered manager had a range of quality‑monitoring systems in place to continually review and improve the quality of the service. Lessons learned from audits and investigations were shared with staff to support ongoing development and improve practice.

Throughout the assessment, the registered and deputy managers were open and honest, acknowledged areas requiring improvement, and were responsive to our feedback.