Quality Assurance & Continuous Improvement Report
Regulation 80 Annual Review
Reporting Period 2025–2026
Contents
1. Executive Summary
2. About Cantref
3. Good Practice Statement
4. Our Commitment to Quality
5. Quality at a Glance
6. Staff Feedback
7. Resident & Family Feedback
8. Healthcare Professional Feedback
9. Overall Themes & Analysis
10. You Said... We Did
11. Quality Improvement Plan
12. Responsible Individual Statement
13. Conclusion & Commitment
1. Executive Summary & Key Findings
This Quality Assurance and Continuous Improvement Report has been prepared in accordance with Regulation 80 of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017. It provides an overview of the quality of care delivered at Cantref Care Home during the 2025/2026 reporting period and demonstrates how feedback from residents, families, staff and healthcare professionals has been used to evaluate and improve the service.
As part of our annual quality assurance programme, anonymous surveys were distributed to key stakeholder groups. We received a total of 30 completed responses, comprising 12 staff, 8 residents and family representatives, and 10 healthcare professionals. This feedback has been reviewed alongside our governance processes, audits, safeguarding activity, complaints, compliments and day-to-day observations.
The feedback was strongly positive, with recurring strengths in staff approach, leadership, communication, partnership working and confidence in the service. Families expressed trust in the care provided, staff described a supportive workplace, and healthcare professionals recognised effective collaboration.
Alongside these strengths, the report identifies opportunities for further development. These include continuing to strengthen communication between shifts, promoting resident choice and independence, maintaining investment in staff learning and development, and ensuring that feedback continues to shape service improvements.
Taken together, the findings demonstrate a well-performing service that is committed to listening, learning and continual improvement.
2. About Cantref Care Home
Cantref Care Home is an independent, family-run residential care home registered to provide accommodation and personal care for up to 21 people over the age of 65. The home supports older people in a safe, comfortable and well-maintained setting, with care planned around each resident’s assessed needs, preferences and personal outcomes.
3. Good Practice Statement
Quality is monitored throughout the year through audits, care reviews, observations, complaints, compliments, resident and relative feedback, staff supervision, governance oversight and partnership working with healthcare professionals. The management team and Responsible Individual review this evidence to identify strengths, address areas for improvement and update the Quality Improvement Plan.
Vision - To provide exceptional care in a home where every person is valued, every voice is heard and every day is lived with dignity, purpose and a sense of belonging.
Mission - To deliver safe, personalised care through skilled staff who work in partnership with residents, families and healthcare professionals to improve the quality of life of every individual who calls Cantref Care Home their home. We are committed to creating an environment where people feel safe, respected and supported to live as independently and meaningfully as possible.
Values - Compassion, We treat every resident with kindness, empathy and understanding, recognising the importance of emotional wellbeing alongside physical care.
Respect - We value every individual, recognising their life experiences, choices, beliefs and personal preferences.
Dignity - We promote independence, privacy and individuality, ensuring residents remain at the centre of every decision affecting their lives.
Community - We support a shared sense of community between residents, families, staff and professionals.
Learning and Development - We actively seek feedback, reflect on our practice and use learning to strengthen the care and support we provide.
Professional Excellence - We are committed to maintaining high standards through strong leadership, ongoing training, effective governance and collaborative working.
4. Our Commitment to Quality - Who was consulted?
In accordance with Regulation 80 of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, Cantref undertakes an annual Quality Assurance review. For the 2025/2026 review, three separate questionnaires were distributed to key stakeholder groups to gather a balanced view of the service.
Questionnaires were developed using Microsoft Forms and distributed electronically by email. QR codes were displayed in the home to support easy access, and assistance was offered where residents or relatives required help to participate. Responses could be submitted anonymously, with respondents also able to provide contact details if they wished to discuss their comments further.
How feedback was gathered
Stakeholder Group -
Staff - Responses Received, 12
Residents & Family Representatives, 8
Healthcare Professionals & External Partners. 10
Total Responses, 30
The resident and family questionnaire was available to all residents, relatives and representatives. The healthcare professional questionnaire was sent to external partners who regularly support residents, including GP, nursing, pharmacy and allied health professionals. All members of staff were invited to complete an anonymous staff questionnaire covering leadership, teamwork, communication, training, wellbeing and job satisfaction.
Feedback is also gathered throughout the year through conversations, residents' meetings, family discussions, compliments, complaints, audits, supervision sessions and partnership working with healthcare professionals.
Survey response rates
Although response rates varied between stakeholder groups, the consistency of feedback across all three surveys provides confidence that the findings reflect the quality of care and support provided at Cantref Care Home.
How findings were analysed
Survey responses were reviewed by the Registered Manager and Responsible Individual. Quantitative responses were analysed to identify trends, strengths and opportunities for development, while qualitative comments were grouped into common themes to provide a deeper understanding of people's experiences.
The findings have been considered alongside information gathered through:
Internal quality assurance audits.
Resident and relative feedback received throughout the year.
Compliments and complaints.
Staff supervision and appraisal processes.
Health and safety audits.
Clinical and governance reviews.
Feedback from healthcare professionals and external agencies.
This combined approach provides a comprehensive overview of the quality of care delivered at Cantref Care Home. Before examining each stakeholder group in detail, the next section summarises the main quality themes that emerged across the review.
5. Quality at a Glance
Theme Summary
Compassion
Residents, families and professionals consistently recognised the patience, empathy and attentiveness shown by staff.
Dignity & Respect
Residents were described as being supported in a way that protects privacy, individuality and personal choice.
Teamwork
Staff highlighted a positive and supportive working culture.
Communication
Families and healthcare professionals praised the openness and responsiveness of the management team.
Safe & Welcoming Home
Feedback consistently described Cantref as safe, friendly and reassuring.
Continuous Improvement - Constructive suggestions have informed our priorities for 2026/2027
These headline themes provide a useful overview of the service. The following sections explore the survey findings in more detail, beginning with the views of the staff team who deliver care and support each day.
6. Staff Quality Assurance Findings
Twenty-four questionnaires were distributed to members of staff, with 12 completed responses received, representing a 50% response rate. Although not all staff chose to participate, the responses provide a meaningful cross-section of staff views. These findings have been considered alongside supervisions, staff meetings, observations and day-to-day engagement to provide a balanced understanding of the service from a workforce perspective.
The results demonstrated consistently high levels of staff satisfaction.
100% of staff agreed that:
They enjoy working at Cantref.
They understand what is expected of them within their role.
Colleagues work together to provide good quality care.
Residents are treated with dignity and respect.
They feel supported by management.
They receive the training needed to undertake their role.
They feel confident carrying out their duties.
They would recommend Cantref as a place to work.
They can raise concerns without fear.
They have opportunities to learn and develop.
These responses demonstrate a strong organisational culture based upon teamwork, openness, mutual respect and individualised support for residents.
Areas showing opportunities for further improvement
Whilst results were extremely positive overall, a small number of staff highlighted areas where further improvements could strengthen the service.
83.3% agreed that
Communication across the team is effective.
Their ideas and suggestions are listened to.
91.7% agreed that
Appropriate equipment and resources are available.
They feel comfortable speaking up when they have concerns.
Although satisfaction remained high, these responses indicate opportunities to continue improving communication and ensuring every member of staff feels fully involved in decision making.
The staff survey continues to demonstrate a committed and engaged workforce, and management values the honest and constructive feedback received. Whilst many of the suggestions identified opportunities for improvement, it is important to consider these alongside previous staff consultation, operational requirements, and the safe delivery of care.
A small number of comments suggested additional support with laundry tasks during the night shift. Management has carefully considered this feedback; however, it is not considered proportionate or financially viable to recruit a member of staff solely to undertake laundry duties overnight. Less than eight months ago, an additional third member of staff was introduced to the night shift to strengthen care provision and provide greater flexibility in managing both resident care and domestic responsibilities. Staffing within this role has stabilised significantly over the past two months, with many shifts now consistently covered, and this arrangement is expected to continue. Management will continue to review workload allocation and support available during periods of unexpected absence.
The survey also highlighted a request for more whole-team meetings. Interestingly, this differs from feedback received during the previous Quality Assurance review, where staff expressed a preference for holding meetings separately according to shifts to improve attendance and discussion. As staff preferences appear to have evolved, management welcomes further discussion to establish the format that best meets the needs of the team. If there is now a clear preference for whole-team meetings, these will be reintroduced where practicable.
Management also recognises comments relating to medication timings and the completion of routine tasks during busy shifts. Medication administration processes will continue to be reviewed to identify opportunities to improve efficiency while ensuring that safe medicines management remains the overriding priority. Where short-notice absences occur and shifts cannot be fully covered, managers will continue to support staff in prioritising essential tasks and reviewing workload to minimise the impact on resident care.
Feedback regarding the management of residents' laundered clothing also highlighted differing expectations between day and night staff. Historically, once garments had been laundered, ironed and placed on hangers, they were left ready for day staff to return to residents' rooms. Following previous Quality Assurance feedback, a system of clearly labelled room discs was introduced to identify clothing awaiting return. This approach was considered a practical solution, particularly as leaving garments hanging outside bedrooms for prolonged periods is not considered best practice from a fire safety perspective. Current feedback suggests that some staff would now prefer night staff to return garments directly outside residents' rooms. Management believes this would benefit from further discussion within the staff team to agree a consistent process that balances efficiency, practicality and fire safety requirements.
Overall, staff feedback reinforces the importance of maintaining open dialogue. Where suggestions are operationally achievable and enhance the quality of care, they will continue to be implemented. Where alternative approaches are required, management remains committed to explaining the rationale behind decisions so that staff understand how feedback is considered within the wider context of resident safety, regulatory compliance and the effective operation of the service. Having considered the staff perspective, the report now turns to the experiences of residents and families.
7. Resident & Family Quality Assurance Findings
The views of residents and families are central to understanding the lived experience of care at Cantref. They were therefore invited to provide anonymous feedback on the quality of care, communication, environment, activities and overall satisfaction with the service.
Eight questionnaires were returned, representing a 38% response rate. Whilst the number of responses was modest, the feedback was overwhelmingly positive and provided valuable insight into both the strengths of the service and opportunities for continued development.
The average recommendation score was 9.9 out of 10, demonstrating a very high level of confidence in the care provided.
Key Findings
The survey demonstrated exceptionally high levels of satisfaction across all areas of the service.
100% of respondents agreed or strongly agreed that:
Staff treat residents with dignity and respect.
Residents receive care that reflects their individual needs and preferences.
Residents feel safe living at Cantref.
Staff respond promptly when assistance is required.
Communication with families is effective.
Families know who to speak to if they have concerns.
Concerns are listened to and addressed respectfully.
Residents are encouraged to participate in meaningful activities.
Residents are offered choice at mealtimes.
Food is of good quality and enjoyable.
Dietary needs and preferences are respected.
The home is clean and well maintained.
The environment is comfortable and welcoming.
Residents' bedrooms reflect their individual preferences.
The service continually seeks to improve.
Particularly notable findings
Every respondent strongly agreed that:
The home is clean and well maintained.
The environment is welcoming and comfortable.
Almost every respondent strongly agreed that:
Management are approachable.
Staff are friendly and approachable.
Communication with families is excellent.
Families feel able to raise concerns.
Residents receive meaningful activities.
What Families Told Us
Several consistent themes emerged throughout the written comments.
Families particularly valued:
· Professionalism, empathy and consistency shown by staff.
· The homely atmosphere and positive relationships within the home.
· Excellent communication with relatives.
· Respectful and dignified care.
· Prompt responses when residents became unwell.
· High standards of personal care and hygiene.
· The wide range of activities, celebrations and outings.
· Staff advocating for residents when accessing external healthcare services.
· Staff taking time to get to know residents as individuals.
Many families described feeling reassured and confident that their relatives were safe, well cared for and supported with genuine warmth.
Representative comments included:
"Excellent service in every aspect."
"The staff are all first class."
"Communication with family members is excellent."
"They are strong advocates for their residents."
"The atmosphere feels homely and welcoming."
Opportunities for Improvement
Only a small number of suggestions were identified. These included:
Exploring the possibility of creating a secure garden.
Providing a private area where families can spend quiet time with relatives if required.
Continuing to support new residents to express their preferences as they settle into the home.
Continuing to encourage independence for residents who may lack confidence.
These suggestions were constructive and reflected opportunities to further enhance an already highly rated service.
Management Reflection
The family feedback provides strong reassurance that the service is valued and trusted. The high recommendation score, alongside positive comments about communication, staff approach and advocacy, reflects consistent confidence in the care provided.
Management is particularly encouraged by the recognition of staff advocacy for residents, especially when working alongside external health professionals. These comments support the wider finding that relationships, communication and timely action are key strengths of the service.
Constructive feedback has also been carefully considered. One respondent suggested the development of a secure garden. Whilst management appreciates this suggestion, families may not be fully aware of the existing measures already in place to ensure residents can safely enjoy the outdoor environment.
The garden adjacent to Brecon Road is secured by a magnetic locking system, which can be activated whenever residents are using the garden. This area is further protected by a second metal gate separating the garden from the car park, providing an additional level of security. The conservatory garden also benefits from a magnetic locking system, allowing residents to enjoy this outdoor space safely. Whilst some residents are subject to Deprivation of Liberty Safeguards (DoLS), these authorisations are intended to ensure that any restrictions placed upon an individual are lawful, proportionate and in their best interests. Consistent with the principles of person-centred care and the least restrictive approach, management carefully balances each resident's assessed risks with their right to enjoy the outdoor environment. Where it is safe and appropriate to do so, residents are actively supported to access the gardens and outdoor spaces, enabling them to benefit from fresh air, independence and meaningful occupation whilst maintaining their safety. In response to previous feedback and our ongoing commitment to enhancing the environment, the home has also recently developed a new outdoor seating area, formerly known as the Care Station, now known as Cantref Cafe. Constructed on a permanent concrete base with attractive timber cladding, this space provides an additional welcoming area where residents can relax or spend quality time with relatives and visitors. Families visiting the home over recent weeks will have seen this development taking shape, and management hopes it will further enhance opportunities for meaningful visits and social interaction.
Management remains committed to reviewing the outdoor environment so that residents can enjoy the gardens safely and meaningfully. The next section considers feedback from healthcare professionals and external partners, offering an independent perspective on the quality of care and collaboration at Cantref.
8. Healthcare Professional Feedback
Healthcare professionals and partner agencies offer an important external view of the service. Those who regularly work alongside Cantref Care Home were invited to comment on care quality, communication, responsiveness and partnership working.
Overall, responses reflected a high level of professional confidence in the service, particularly in relation to communication, responsiveness and collaborative working.
Key Findings
Feedback from professionals consistently identified several strengths within the service.
Professionals recognised that:
Residents receive care that is attentive, respectful and tailored to their needs.
Staff demonstrate professionalism and respect in all interactions.
Communication between Cantref and external professionals is open, timely and effective.
Staff work collaboratively with multidisciplinary teams to support residents.
Residents' wellbeing remains at the centre of decision making.
Management are approachable and responsive.
The home demonstrates a willingness to learn, adapt and develop practice.
What Professionals Told Us
Common themes identified included:
“Professional and knowledgeable staff”.
“Excellent communication”.
“Strong working relationships with external agencies”.
“Staff who know residents well”.
“Prompt responses to changing health needs”.
“Effective advocacy for residents”.
“A positive atmosphere for residents and visitors”.
“Respectful partnership working”.
Professionals particularly recognised the willingness of staff to work collaboratively to achieve the best possible outcomes for residents.
Examples of Excellent Practice
Professionals highlighted several examples of good practice, including:
Staff acting as strong advocates for residents when accessing healthcare services.
Prompt recognition of deteriorating health and timely referrals.
Sensitive and attentive support during periods of illness.
Clear and timely communication with relatives and healthcare professionals.
A supportive environment for residents and visitors.
Opportunities for Improvement
The feedback identified very few areas requiring improvement.
Where suggestions were made, these will continue to be considered as part of the home's ongoing approach to service development and quality learning.
Professional feedback provides valuable independent assurance that Cantref works effectively with external agencies to achieve positive outcomes for residents. It is encouraging that professionals recognised attentive care, effective communication and strong multidisciplinary relationships.
Management was especially pleased to note comments recognising staff as advocates for residents when working alongside health and social care professionals. Supporting residents to access the right services at the right time and ensuring their wishes, needs and best interests are represented is a key principle of our care philosophy.
Cantref recognises that good outcomes are achieved through strong partnerships with families, healthcare professionals and community services, and remains committed to maintaining these relationships.
Although few improvement areas were identified, professional feedback will continue to inform service development, staff learning and practice discussions.
9. Overall Themes & Analysis
When the feedback from residents, families, staff and healthcare professionals is considered together, several consistent themes emerge. These themes provide a balanced picture of the service, highlighting areas of strong practice while also identifying opportunities to further strengthen care, communication and the environment.
Strengths identified across the review
· A positive culture where residents are treated as individuals and supported with dignity, choice and respect.
· Strong confidence from families in the quality of care, communication and responsiveness of the team.
· A committed and supported staff team who understand their roles and feel confident in their work.
· Effective partnership working with healthcare professionals and external agencies.
· A clean, homely and well-maintained environment that supports comfort, safety and wellbeing.
Areas for continued focus
· Maintaining clear communication between shifts and ensuring staff continue to feel involved in-service development.
· Continuing to promote resident independence, choice and confidence in daily routines.
· Further reviewing access to outdoor areas and quiet spaces for residents and families.
· Sustaining investment in staff development, equipment and environmental improvements.
· Ensuring feedback remains central to decision-making and future planning.
Overall, the analysis demonstrates strong foundations and clear priorities for the next stage of development. The following section sets out how specific comments and suggestions have been considered and acted upon.
Learning from Significant Events
During the reporting period, Cantref Care Home managed a safeguarding concern in accordance with the Wales Safeguarding Procedures and the home's safeguarding policy. Appropriate referrals and notifications were made, and the service worked openly and collaboratively with the relevant agencies throughout the investigation.
The safeguarding enquiry has now concluded, and the case has been formally closed.
Whilst the investigation did not identify ongoing concerns requiring further action by the service, the management team viewed the process as an important opportunity for reflection. Practice, communication, documentation and safeguarding procedures were reviewed to ensure that lessons learned were embedded within the service.
10. You Said... We Did
The Quality Assurance review has provided an opportunity to listen carefully to comments from residents, families, staff and professional partners. The table below summarises key messages received, the action already taken and the further work planned where appropriate.
Staff would like communication and team discussions to remain a priority.
Management will continue to review meeting arrangements, handover processes and opportunities for staff to share ideas, ensuring the format remains practical and inclusive.
Some staff felt laundry responsibilities and task allocation could be reviewed.
Workload allocation will continue to be monitored. Existing night staffing arrangements have been strengthened, and management will support staff to prioritise essential duties during busy periods or unexpected absence.
Families suggested further consideration of garden access and quiet spaces.
Existing garden safety measures have been reviewed and explained. The new Cantref Cafe seating area provides additional space for residents and visitors, and outdoor access will remain under review.
Residents and families value activities, outings and social opportunities.
The home will continue to support meaningful activities, celebrations and community links, while encouraging residents to express their individual preferences.
Healthcare professionals valued communication, advocacy and partnership working.
These strengths will be maintained through ongoing multidisciplinary communication, timely referrals and continued collaboration with external services.
This approach demonstrates that feedback is not viewed in isolation. It is considered alongside safety, regulation, staffing, resources and residents’ best interests so that actions are practical, proportionate and focused on positive outcomes. The priorities identified through this process are brought together in the Quality Improvement Plan.
11. Quality Improvement Plan
The following Quality Improvement Plan reflects the themes identified through the annual review. Actions will be monitored by the Registered Manager and Responsible Individual and reviewed through ongoing governance arrangements.
Priority Area / Planned Action / Intended Outcome
Communication and staff engagement - Review team meeting formats, handover arrangements and opportunities for staff to contribute suggestions. The intended outcome is that staff feel listened to, informed and involved in the continued development of the service.
Resident choice and independence - Continue to support residents to express preferences, make choices and participate in daily routines and activities where possible. The intended outcome being that Residents experience greater confidence, autonomy and meaningful involvement in daily life.
Environment and outdoor access - Continue to review garden access, quiet spaces and the use of the Cantref Cafe seating area. The intended outcome is that Residents and families have safe, comfortable and meaningful spaces to spend time together.
Staff learning and development - Maintain training, supervision and development opportunities aligned to residents’ needs and regulatory expectations. The intended outcome being that Staff remain confident, skilled and supported in delivering high-quality care.
Sustainability and service investment - Continued planned improvements, including environmental upgrades, sustainable cleaning and laundry systems, and future wet room development. This is so that the home remains well maintained, efficient and responsive to residents’ changing needs.
Progress against this plan will be reviewed throughout the year and updated as actions are completed or new priorities emerge. The Responsible Individual Statement that follows confirms the service’s commitment to maintaining high standards and supporting further development.
12. Responsible Individual Statement
As Responsible Individual, I have reviewed the feedback, governance information and improvement priorities set out in this report. My oversight gives me confidence that Cantref remains a stable and responsive service, while also highlighting the importance of continuing to challenge ourselves and plan carefully for the future.
I am encouraged by the confidence expressed by families, staff and professional partners, particularly in relation to communication, teamwork and the way residents’ needs are understood. These findings reflect the commitment of the staff team and the positive culture that has developed within the home.
My role is to ensure that this positive feedback is not viewed simply as reassurance, but as part of an ongoing cycle of oversight, reflection and action. Where suggestions have been made, I have considered them alongside resident wellbeing, safety, staffing, resources and regulatory requirements so that decisions remain proportionate, transparent and in the best interests of those living at Cantref.
During the year, I have also continued to oversee investment in the home environment and the daily experience of residents. This has included the refurbishment of Bedroom 9, incorporating an LED window to improve light and stimulation, as well as new dining furniture and upgraded bedroom tables to enhance comfort and presentation across communal and private spaces.
Sustainability remains an important part of our forward planning. The investment in the iMop floor cleaning system supports both environmental sustainability and operational efficiency by reducing water consumption and chemical use whilst maintaining high standards of cleanliness. We are also introducing a more sustainable laundry system that combines stain removal, washing and fabric conditioning within a single solution, reducing packaging, waste and stock complexity while maintaining infection prevention standards.
Looking ahead, I will continue to support planned improvements that respond to residents’ changing needs. These improvements demonstrate our commitment to continually reinvesting in the home, ensuring that both the environment and the quality of residents' daily lives continue to evolve alongside their changing needs.
I would like to thank residents, families, staff and professional partners for their contributions to this review. Their feedback will continue to inform my oversight of the service and support the home to maintain high standards while progressing the priorities identified for the year ahead.
13. Conclusion & Our Commitment
This review provides clear assurance that Cantref Care Home continues to deliver a safe, responsive and well-led service. Feedback from residents, families, staff and healthcare professionals has been strongly positive and has helped identify focused priorities for the year ahead.
The findings show a culture of openness, reflection and learning, supported by practical action through the Quality Improvement Plan. Suggestions have been considered carefully, with decisions guided by resident wellbeing, safety, regulation and the long-term sustainability of the service.
Above all, we remain committed to ensuring that every person who lives at Cantref receives care that is safe, compassionate, respectful and centered around what matters most to them.