Carolyne House

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. 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. The management team had on ongoing action plan they were working through to drive improvements. There was a culture of support being provided to the care staff working at the service. The registered manager was actively supported by the regional manager and deputy manager. The management had clear values and were aware of the direction they wanted to take. The registered manager had developed a listening culture where staff felt they are available for them to talk to. A member of staff told us, “The managers will help us with the residents if we need it and are always available to support. They are never just sat in their office. They are always around and helping us.”

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 was clear about their roles and had the skills, knowledge and experience to perform their job. The registered manager was visible within the service, leading by example and modelling inclusive behaviours. The registered manager told us they felt well supported by the provider to drive improvements and develop the service in a direction that will promote positive outcomes for people and staff. The regional manager supported the registered manager with monthly provider monitoring visits and created an action plan following each visit which the registered manager worked through. A health professional told us, “The home manager is approachable and responsive, [manager] is always happy to work with us in relation to any concerns raised.”

The Chief Operating Officer told us, “The home is moving in a positive direction. The manager is working hard to achieve positive outcomes for people living in the service. A lot of people preferred to stay in their bedrooms however, the manager encourages everyone to socialise together and has arranged many excursions for them all. The manager prioritises residents’ wellbeing and best interests. The manager suggested building an extension to the home to create a larger communal area for the residents which has been approved, and the building work is due to start next month.”

The service fostered a positive culture where people felt they could speak up and their voice would be heard. The registered manager had policy and processes for staff to follow on ‘whistle blowing’.  We reviewed staff meeting minutes and saw they included information about the service as well as reminders about training, staff rotas, safeguarding, incidents, infection control, weight management and PPE. There was detailed action plans completed to evidence how issues raised were to be addressed, dates to be achieved and if actions had been resolved or remained outstanding. The registered manager held regular residents and relative meetings for people to share their thoughts about how the service ran and if they had any concerns or suggestions. A staff survey had been sent out for staff to complete and give their feedback. The management collated the results to analyse for any themes or trends. The survey results were discussed during supervisions and staff meetings. The registered manager sent out a monthly survey to all health professionals visiting the service. Results were analysed for themes and trends and shared with relevant professionals.

A staff member told us, “I took the job and have stayed in the job because of the manager. They are a model for all of us, they are an extraordinary person, I teach my kids to be like her. I have worked for years in another country and here, and I have never seen a person that is so nice and so hard working. I feel I can raise any concerns with them. I also like the team I have been here for years because of the team, we really communicate, and we all know what we are really good with and what we need support with. I also know that if I have a personal issue, I will get cover and get support.”

The service valued diversity in their workforce. The provider worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. There was a policy in place to protect staff from harassment and bullying and a focus on protected characteristics under the Equality Act. The registered manager had developed an inclusive workforce and recognised the value of diversity amongst the team.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. The registered manager worked closely alongside the regional manager and had established a number of audits which provided them with a good oversight of the service. The regional manager completed monthly provider visits and devised an action plan which was being worked through. The registered manager had given staff a clear direction of their vision for the service. Staff understood their role and contribution in sustaining improvements. A health professional told us, “[Registered manager’s name] is an excellent manager. They are very helpful but always mindful of the needs of their residents if we contact in regard to accepting an admission. They are very approachable.”

The service 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 management and staff shared the same goal to provide positive outcomes for people. The registered manager encouraged staff to discuss and share ideas for improvement and innovation. A health professional told us, “I have no issues with Carolyne House from the Manager, deputy manager, nurses, care assistance and domestics/ cook. They are all very supportive. Communication is very good, and they always escalate any issues if any when they need to. The overall environment is welcoming and person centred. Feedback is always positive.”

Another health professional told us, “From our point of view, I think [manager] has done a terrific job with Carolyne House and its improved noticeably since they became manager. I think that’s helped by the fact [manager] is very caring, approachable, knows their residents like the back of their hand and communicates with us extremely well. Also I think their nature and philosophy is picked up by the other staff and they follow their lead in terms of their general approach to care, how they deal with professionals, the person centred care with residents and the way in which they communicate but also in terms of knowing their residents. I think the home is immaculate, welcoming and that’s also something [manager] has made a priority since becoming manager which makes it a great environment to work and live in. Generally, I think it’s a very good home and certainly well lead from our perspective which is credit to [manager] but also feel the staff there do a great job.”

Another health professional told us, “Carolyne House is the only care home that emails me regularly regarding their residents or any hearing aid problems. The communication is always very good, and they always reply very promptly.”

The service 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. There was a learning culture at the service with learning shared from incidents, accidents, safeguarding and complaints, to inform and improve on-going care. The management was actively supporting staff with learning and innovative ways of working at the service. Staff were encouraged to develop their skills and were supported to attend training courses to obtain nationally recognised qualifications. One member of staff told us, “I have completed lots of training here and they are always encouraging us to develop our skills. There are always opportunities for growth and development.”

During meetings the registered manager had identified staff to take on additional roles as champions for IPC or end of life and were upskilling staff to enable them to perform these roles effectively.