Cantley 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 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 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 in breach of legal regulation in relation to the governance of the service.

This service scored 62 (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 felt valued and supported. We found people were supported to carry out their lives as they wanted, and staff intervened in people’s best interests.

The provider had inclusive leaders who understood the context in which they delivered care, treatment and support. Leaders had the skills, knowledge, and experience of managing the service. Staff told us they had opportunities to develop within the service and progress if they desired. Staff felt supported by the management team. People and relatives knew the registered manager and found them approachable.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff had access to the whistle blowing procedure and felt comfortable to raise concerns and felt they would be listened to.

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 told us they felt supported and could discuss things with the registered manager. Staff told us the registered manager was understanding about commitments they might have outside work and tried to facilitate a flexible working approach.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. The provider had systems in place to monitor the quality of the service, but these did not operate effectively. Systems were disorganised and there was a lack of oversight. For example, issues we found during our assessment in relation to medicine management, risk and environment had either not been previously identified or not actioned in a timely way.

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 provider worked in partnership with various community health and social care professionals and external agencies. The registered manager told us they regularly consulted these external bodies and professionals, welcomed their views and advice, and shared best practice ideas with the whole staff team.

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. We found opportunities to learn lessons and improve the service had been missed. For example, the service had been instructed to take actions based on a recent fire risk assessment carried out by an external professional. However, these had not been resolved in a timely way. On our first site visit we informed the registered manager and provider of safety concerns arising from very hot radiators. On our second site visit this was still unresolved.