St Catherines 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 the last inspection, we rated this key question as good. At this inspection this key question 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.

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.

Staff were positive about how the team supported people live their best lives. A staff member said, “We have a very good, committed staff team with low turnover. We know the residents very well. I am happy with my role here.”

The provider had a service action plan in place. This captured areas identified by the team as needing improvement and included new ideas to further improve people’s experiences and staff skills.

Feedback from people and their relatives was obtained through meetings, surveys and care plan reviews. In addition, people, relatives and visitors told us the registered manager was available, approachable and helpful. Meetings were held with staff to share and receive information.

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 and relatives were positive about the registered manager and staff team. A relative said, “The manager is very obliging and approachable.”

Staff were positive about the culture and approach in the home. A staff member said, “I am happy in my role here.” Staff told us they would have a relative of theirs live at the home. The registered manager told us they were most proud of, “The caring staff team, and the nurses experience, it gives us confidence.”

There were systems in place to help ensure care was personalised and people had a positive experience. A function of the provider’s system included an overview of people’s involvement and engagement with activities, social interaction and time with family or friends and general wellbeing. Where this needed more input from staff, actions were developed for staff completion.

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

Staff said the registered manager engaged with and involved them. A staff member said, “We can speak up and our reviews matters we always share our views what we can do, and it worked most of the time.” The provider had whistleblowing policies in place.

Staff told us the management team were visible and approachable.

There were resident, relative and staff meetings. A survey for people, relatives, and staff had been carried out by a care providers association. Actions were implemented and recorded where needed in response to feedback. A further survey was due to be completed.

Relatives had regular contact with staff and managers via assessments, care planning and events in the home. This enabled effective communication and sharing of feedback.

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.

Staff felt supported and respected by the management team. A staff member said, “I am happy working here and I would recommend it.”

The provider had an equal opportunities policy which they adhered to. Staff employed demonstrated different backgrounds, ages, genders and ethnicity which was a benefit for the people they supported.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. However, there were some gaps in oversight.

There were governance systems to help identify and address any issues. These systems covered key areas such as care plans, health and safety, clinical needs, falls and medicines. Where issues were found, a plan was developed and actions taken to resolve it. However, the areas needing improvement we found during this inspection had not been identified as part of the governance systems. We discussed this with the registered manager and the director for the service. Following our feedback the management team implemented immediate actions to address the points raised and these were in progress at the time of this report, giving assurances remedial work would be completed.

The registered manager shared, ‘We use a digital system in the home which allows for easy access to data. It makes it easy to communicate with the staff; they can send messages to each other or to the whole team easily. Staff that are off duty can still read messages when they come back to work which means they do not miss out on important updates. Audits are undertaken via the system, and actions can be sent to specific individuals. As a manager you always have a good idea of what the clinical governance looks like. When, for example inspections are due the system lets you know. It is easier to keep on top of things even with a busy workload.’

The management team responded to any complaints, feedback and requests.

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 and relatives told us they were supported to access other professionals.

A visiting health and social care professional told us they had no concerns about the service.

The management team worked with agencies outside of the organisation. This included health and social care agencies and benefited people and the service. This included a care providers association to access training and updates, and other health and social care teams so health care and support were accessible.

The service had visitors from local community schools, colleges and social groups.

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.

Staff told us information was shared and training provided to drive improvements and innovation. A staff member said, “I strongly believe that we always been informed by managers updating care plans and in handover or staff meetings, our management take very seriously if there’s any concerns, it’s discussed in handover and they speak to all staff.”

The provider had developed systems to help identify any learning and improvement areas. They had plans to further improve people’s experiences. This included picture menus and a resident of the day process. The registered manager shared, ‘I have introduced the role of Resident Assistants as a way of improving resident's hydration and also to add some engagement. I have also introduced ‘TOOLS down’, which used to be at 3pm but staff find it easier to do this throughout the day instead of a particular time. This is when staff stop what they are doing and offer someone to one time to a resident for about 10 minutes. This is a way of increasing engagement with the residents.”