Maria Residential 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 requires improvement. At this assessment the rating has remained 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 service was in continued breach of legal regulation in relation to governance at the service.

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.

Staff told us they were aware of the vision from the provider to ensure people were treated with dignity and respect. Staff told us they understood the culture. One member of staff told us, “Safe, kind, respect, choice, independence. I live this every day, listen, respect, follow plans, raise concerns.” Another member of staff told us they demonstrate the providers values by “listening to the residents, respecting their privacy, giving them choices, following their care plans and raising any concerns I have about their health, safety or wellbeing.”
 

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

The provider and registered managers were not able to demonstrate they had established effective governance, quality assurance and improvement systems. The absence of robust oversight, failure to act on feedback, poor record keeping and ineffective monitoring meant leaders had not ensured a culture that consistently supported safe, high-quality and person-centred care

The deputy manager had not kept up to date with training and therefore was not demonstrating the importance of training to junior staff.

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

Relatives told us they had opportunities to speak up, comments included, “When we visit, the carers are always forthcoming, we have no concerns at all” and “We text each other all the time and if I ask [registered manager] to call me, he always does.”

Staff told us they would speak up when needed. One member of staff told us, “If I have a concern about a resident or I’m unsure about something, I know it’s important to raise it and ask for help rather than ignore it.” Other comments from staff included, “I can speak to the manager anytime” and “Always ask if worried.”
 

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider had not demonstrated workforce arrangements promoted equality or ensured all staff had equitable access to the training, assessment and support required for their roles. Staff were not supported to attend training in a timely manner to ensure their skills were updated.

However staff told us, they did feel supported, one member of staff told us, “Everyone at Maria Residential Home is very kind, friendly and supportive towards me. I have good relationship with my management and colleagues.”

The provider told us “We provide a comprehensive induction and pastoral support package to ensure they [staff] are fully integrated into our team and the local community. This includes practical support with housing, cultural orientation, and ongoing mentoring from experienced colleagues.”
 

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Governance and management arrangements were not effective in ensuring the provider and staff consistently delivered safe, high-quality care. The provider and registered managers had not established robust systems to assess, monitor and improve the quality and safety of the care and support provided to people.

Quality assurance processes lacked consistency and had not identified or addressed significant shortfalls in staff competency, care records, risk management, staffing and compliance with people’s assessed needs. The registered manager acknowledged some audits had been completed, however, auditing was not consistent or fully aligned with the provider’s quality assurance policy. Therefore, the provider and registered managers could not demonstrate effective oversight at Maria Residential Home or assurance identified risks were being appropriately managed.

Records were not always accurate, complete or contemporaneous. Daily notes for people who required transfers using a hoist and 2 trained staff did not record how transfers had been completed, despite people being observed out of bed during our visit. Governance systems had not identified these recording gaps or provided assurance people’s mobility and transfer needs were being met safely and consistently.

Care plans were not reviewed within the provider’s expected timescales. Overdue reviews included communication, personal care and mental health care plans. This meant the provider and registered managers could not be assured staff had access to current information which accurately reflected people’s needs, risks and preferences.

Policies and procedures were not consistently reviewed, implemented or reflected in practice. Some policies referred to staff who no longer worked at the service and described processes which had not been carried out. For example, the falls policy stated staff received falls management training during induction and annually thereafter; however, this training was not included on the training matrix. The provider’s systems had not identified or addressed the gap between its written policies and operational practice.

There was no systematic approach to assessing staffing requirements across the service. Governance arrangements had not identified staffing levels were insufficient to consistently meet the assessed needs of people who required support from two staff members. The provider and registered managers could not therefore demonstrate staffing decisions were based on people’s current needs and associated risks.

The provider and registered managers had not acted promptly on feedback from external partners. On 18 August 2026, the local authority raised concerns about the absence of risk assessments for emollient and flammable medicines. These risk assessments remained unavailable when were at the home on 22 September 2026. The delay in taking action exposed people to an increased risk of harm and demonstrated systems for responding to feedback and driving improvement were ineffective.
 

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 provider worked with external healthcare professionals, they told us, “We coordinate with chiropodists, optometrists, dietitians, and speech and language therapists, organising appointments and ensuring that recommendations are implemented and reviewed.”

People and their relatives told us they were supported to maintain a role as a friend or attend local social clubs. One person told us “I go to a Day Centre… I play dominoes and cards… they pick me up in a minibus.” One relative told us, “I am really glad the friends managed to get in; they have known each other for over sixty years… it is important that they can visit [person].” Another relative told us, “[person] goes out shopping with a carer.”
 

The provider did not always focus on continuous learning and improvement across the organisation and local system.

The provider and registered managers had not effectively used quality assurance systems to identify, monitor and learn from concerns within the service.

There was limited evidence learning had been applied following our previous inspection. The continued breach identified during this assessment demonstrated lessons had not been effectively learned or embedded, and improvements had not been sustained over time. As a result, the provider had not demonstrated a commitment to continually evaluating and improving the service.

However, the provider had been working on developing an electronic platform to record people’s care and store management records for Maria Residential Home. The provider was implementing this new electronic system in a phased approach at the home.