St Gregory's House Limited

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 requires improvement. At this assessment we found a new breach of regulation in good governance and the rating has remained requires improvement. This meant governance management was not always effective or consistent.

This service scored 54 (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.

The new management team had the appropriate skills and experience to lead effectively, understood the risks and priorities for the service and acted with openness and honesty during this assessment. However, a lack of consistent leadership and provider oversight had resulted in several shortfalls which had affected the quality of the service and people’s care.

The provider did not have consistent leaders who understood the context in which care, treatment and support was delivered or had the skills, knowledge, experience and credibility to lead effectively.

The lack of consistency in management over recent times was demonstrated during this assessment and we found areas for improvement. The provider level of oversight during the absence of a registered manager had not been effective in identifying the shortfalls we found. Areas of concern found during the assessment had also not been identified through the systems and processes used for monitoring the quality and safety of the service.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. However, the formal system for providing opportunities for staff to speak up and discuss their development on a one to one basis were not always consistently followed.

Regular team meetings between the management team and staff took place. Staff were given opportunities to discuss performance via a supervision and appraisal process. However, the frequency of staff supervisions had not always been completed in line with the provider’s own policies. Staff told us they could speak up to one member of the management team in particular about anything and felt they were listened to and things would be acted on.

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.

A proportion of the staff team were from overseas and the provider operated a sponsorship scheme. The staff we with spoke were very positive about their experiences of being recruited and working at the home. The diversity of the staff team was clearly supported by the provider and management.

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.

There was a newly established management team in the home and new arrangements of delegation and responsibilities had been implemented for the running and oversight of the service. However, the day-to-day clinical oversight currently was an added responsibility to the nurses on duty until a designated clinical lead has been recruited. There were a range of quality monitoring and auditing in place. However, improvements were needed as the processes in place were not always effective in identifying concerns we found.

Records were not always accurate or current about people’s needs. The management and oversight of accidents and incidents was not always recorded effectively. Some recruitment files had not been consistently completed, and no regular audits on the files had been completed. The recording of best interest decisions and consent was not always completed in line with the MCA. Medicines care plans, records and oversight were not always consistent or effective.

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.

Staff and management were working in close collaboration with the local GP, practice staff and other health professionals to provide effective care and treatment. The new manager expressed their wish to develop more working relationships such as with other providers for sharing learning.

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.

In the new management team, there was a strive for improvement and development evident. However, there were aspects of this assessment that found a number of areas for improvement. Opportunities for where lessons needed to be learned were being missed because the oversight and management of information from accidents and incidents was not always being used.

However, where learning had been recognised this information was shared with the staff team.