St Catherines Care 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 inadequate. 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 governance at the service. Improvements were found at this assessment and the provider was no longer in breach of this regulation.

This service scored 61 (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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.Since out last inspection, overall feedback indicated work was being undertaken to improve the culture and a shared direction. Staff told us, “There’s more team work with staff and we’re getting more guidance now.” However, systems needed to be fully embedded, as some feedback indicated staff didn’t always feel listened to or able to freely share issues with the provider.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Overall, leaders had the skills, knowledge, experience and credibility to lead effectively, or they did so with integrity, openness and honesty. Overall, feedback indicated there had been recent improvements in the management of the service. Some feedback indicated there was increased confidence in leaders and their capability to lead. The management team were motivated to make improvements and were working on an improvement plan, with processes and systems being implemented and embedded.

However, other feedback suggested when issues were raised, staff didn’t always know if they’d been addressed and some people felt managers needed to be more visible to fully understand performance issues. The registered manager said staff may not always be aware of the activities being undertaken to manage the service, and said they would further work to ensure effective communication and feedback occurred throughout the team. The provider had arranged for managers to develop their management skills through further training.

People did not always feel they could speak up and their voice would be heard. The provider had a ‘Raising Concerns and Freedom to Speak Up’ policy in place. This included the name and contact details for the Freedom to Speak up Guardian at St Catherines and how concerns would be dealt with. There was a code on display for staff, which gave them access to a direct live chat with the provider, to enable them to give feedback or raise issues.

Feedback indicated that whilst some staff felt able to speak up, others did not feel able to share their views fully with the provider. Managers had made improvements to ensure individual and team meetings were held more frequently to encourage feedback. However, some staff and relatives said managers worked mainly in the office and felt it would be beneficial to see them around the building. This was an area the registered manager was continuing to focus on and improve.

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. The provider had an equality and diversity policy in place.

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. Since our last inspection, there was an improving picture and managers had worked to implement changes and make improvements, these needed to be fully embedded, sustained and built upon. The provider had recruited new staff to various senior management roles. A new regional manager and clinical lead had been supporting the registered manager to implement more effective governance systems.

The provider needed to ensure ongoing improvements were maintained to ensure record keeping was robust, that staff followed plans to manage risk and there was always sufficient staff, especially when there were unexpected absences. We found there had been an oversight in relation to meeting the requirements to notify CQC of certain events.

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 management team were working in partnership with the local authority and health partners to make improvements in line with an identified action plan. They had made some progress and were working to complete all the identified actions.

The activity staff worked in partnership and invited people from the community into the home, such as singers or a church service.

The provider 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. Since our last inspection the provider had focused on improvement, and they had met the breaches of regulation. The provider had sent out a recent survey to people, staff and relatives and implemented other initiatives to seek feedback about the service, to support improvements.

Overall, staff told us opportunities to provide feedback and contribute to learning had improved. For example, one staff member said, “We bring our concerns during supervision and will be asked questions for improvements.” The provider held meetings, whereby managers for several of the provider’s other location shared wider learning and insight.