St Mary's 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 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 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

People were supported by staff who were happy in their work. One member of staff told us, “I look forward to coming to work every day.” Staff felt supported by the registered manager, whom several described as “approachable.” One member of staff said the registered manager, “Has a chat with me every day. She has time for everyone.” Another member of staff said the registered manager was a “great listener.”

The service involved relatives in activities, assessments, social events and decision making. The service used a private social media account to keep relatives up-to-date with events at the service. This was particularly welcomed by relatives living abroad.

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

The provider carried out surveys of people, relatives, visitors and staff to identify the impact of care and support and the improvements that were required. Surveys were reviewed by the management team and acted upon. For example, following the trialling of electronic records. the feedback from people was negative as they perceived staff to be using mobile phones. Consequently, and following further consultation, the system was discontinued.

People and staff told us they were comfortable sharing their views. One person told us they discussed their bedroom and activities with the registered manager and were happy with their response. A member of staff told us, “You can speak about anything” Another member of staff said, “Managers respond when you come up with a good idea.” A third member of staff told us, “We always talk about changes. We are all responsible for all of the people. Needs can change really quickly - we need to be on top of them.”

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider did not always have clear responsibilities, roles, systems of accountability or 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 carried out a range of checks to establish the quality and safety of the care and support people received. However, these checks did not always identify and address shortfalls. For example, health and safety checks and environmental audits did not identify the risk of people falling from height due to unrestricted windows.

Staff were clear about their roles and those of colleagues. Staff met regularly in team meetings and supervision meetings to discuss people’s care and support. However, these were often informal meetings and rarely minuted. This meant that matters discussed were not always recorded for later review or to confirm the satisfactory completion of actions. Between the dates of our two assessment visits the provider recommenced the process of maintaining records of meetings. We will be monitoring to ensure this continues.

Notwithstanding the above the above, the provider routinely audited people’s care records, activities and medicines. Important health and fire safety checks were also carried out by contractors and reviewed by the registered manager.

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.

People were supported to maintain relationships, receive visitors and engage in community activities. The provider hosted a range of visitors to lead activities at the service. For example, performers entertained people with Spanish dancing and belly dancing and pianist-led singalong sessions. Children from local nurseries visited and socialised at the service. People were also visited by representatives from faith organisations.

People benefited from well-being activities undertaken in partnership with community activities. These included visiting pet therapists, a hairdresser, chiropodist, volunteers taking people out for coffee mornings, and chair exercise classes. One person told us, “We sit down and use the top of our bodies. It keeps me fit.”

The provider’s partnership working promoted people’s health. People received support at the service from opticians, occupational therapists, district nurses, the GP, dentists and speech and language therapists. This meant people’s changing health needs were met in a timely manner.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.