St Mary's Convent and Nursing 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 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 supported a positive culture at the home. The provider had developed values and vision for the service. This identified the ethos and what makes the home special. This was developed with staff. The aims, values and objectives were shared with staff in the staff handbook. Staff felt the people, relatives and other staff were like family with a staff member saying, “I feel the home is like an extension of my family.” A staff member told us, “Residents are at the heart of the care delivered and their wishes and preferences enhance their wellbeing. Each person’s care needs were unique to them.” Photographs of all the staff working in a specific area were displayed in communal areas so people could recognise them. People and relatives were happy with the care provided with a person commenting, “I am so happy we found out about this home, this is the best team.” Staff demonstrated a clear understanding of people’s care needs and how they wanted their support provided. Interactions between staff and the people they supported were kind, friendly and supportive.

The provider had a senior staff team who understood their roles and responsibilities. People spoke positively about the registered manager. Their comments included, “This manager is the best I have come across, and this place is what it is because of them” and “I see [the registered manager] all the time, she is the loveliest lady.” Relatives praised the registered manager with a relative telling us, “[The registered manager] has a genuine love and passion for making sure people are well looked after.” A relative told us they were happy the CQC assessment had taken place so we can see how lovely this team is. The registered manager had the appropriate experience and understood their responsibilities as registered manager. Staff felt supported by senior managers.

The provider had processes for people, relatives and staff to raise any questions or concerns. The provider had a policy and procedure for raising concerns, speaking up and whistleblowing. Staff completed training on raising concerns and whistleblowing. Staff felt able to speak to senior managers if they had any questions or concerns. People and relatives were confident to raise any concerns and understood the complaints process.

The provider valued diversity in their workforce. The registered manager told us, “St Mary’s has a very diverse community of staff many who have worked at the home for years. We recruit locally but don’t have a high turnover of staff, but we would always be mindful of our staff reflecting our local community.”

The staff newsletter celebrated the diverse staff team and their range of experiences and knowledge.

The registered manager said staff were supported to celebrate their religious events and they could access the chapel and prayer room at the home. The provider had policies which protected staff members rights in line with legislation.The provider identified where staff may need extra support in their role and this was provided.

The provider had effective quality assurance processes to monitor the quality and safety of the care and support being provided. A range of audits were completed including an audit which reviewed the internal and external environment, health and safety, staffing, meals, complaints and safeguarding. Feedback was obtained from people living at the home, relatives and external stakeholders. Action plans were developed following the audit and were reviewed and updated. The provider had a contingency plan in place to ensure care could be provided in case of an emergency occurring at the home. The provider had systems to ensure people’s personal information was managed securely in line with current legislation.

The home had a board of trustees who meet 4 times a year. They oversee the running of the home and work with senior staff to make decisions about managing the home. Staff completed training on how to ensure the home was environmentally friendly. There were green champions in each are of the home.

The provider worked with other professionals and organisations to provide care and support to meet people’s health and wellbeing needs. There was regular contact with the community nurse, GP and tissue viability nurse. The provider worked with an optician, chiropodist and audiologist. There were volunteers from the local community who visited to support people and visits from local schools for activities. People were supported to attend local parish lunches and religious services. The provider took part in a university led academic survey to investigate the occurrence of social isolation.

The provider ensured there were systems and processes to promote continuous learning, innovation and improvement. Staff completed a range of training including specific courses to support people with hearing loss and with end-of-life care. The senior staff shared any actions identified following an incident, accident or complaint with staff so lessons could be learned for improvement. The registered manager kept up to date with current legislation and best practice by attending provider forums run by the local authority, accessing information from Skills for Care and attending adult social care conferences. Action plans were developed when areas for improvement were identified. There were regular meetings with staff and newsletters to share information and innovation.