St Marys

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 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 service was in breach of legal regulation in relation to governance at the service due to ineffective oversight of risk including insufficient checks when recruiting staff.

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.

While staff generally understood their roles, there was limited evidence they were supported to see how their work contributed to broader goals. The provider had not created a culture where learning from mistakes was used to drive improvement. The provider understood and acted on the duty of candour, which is their legal responsibility to be open and honest with people when something goes wrong. There was no effective system in place to regularly check progress or measure how well the service was improving. This made it harder to know whether changes were working or if further action was needed.
Despite this, the management team were visible and had a strong informal oversight of day‑to‑day practice. They had regular informal observations of care being delivered with the outlook of prevention of incidents before they occurred. The registered manager said, “I am a manager who has always been out there with the staff, and I don't sit around in an office, and I think they respect that.” Although the provider had begun to make some changes, these were still at an early stage or had only started following our assessment and were not fully embedded into everyday practice.

The provider did not consistently have skilled and inclusive leaders in place, 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.We found concerns with recruitment files and training. Recruitment and succession planning processes were not sufficiently robust to ensure safe, inclusive, and values-driven leadership appointments. Some recruitment records were incomplete, with missing documentation.This raised concerns about the quality of the pre‑employment checks.

However, the registered manager was supported by the provider. Staff and managers were described as kind, caring and compassionate, and we observed warm interactions during our assessment. The registered manager was well known to people using the service and was actively involved in day‑to‑day care, which relatives and residents told us they valued. The registered manager said, “If there is something that will make them comfortable and you ask [the provider] will provide. It is about making sure they are well cared for. Respected and loved. They are not just a number they are a person.” The leadership team were visible and accessible, and staff felt able to approach them when needed. One relative said, “[registered manager] runs things with a rod of iron in a good way, and they tell the staff when something needs to be changed and makes sure it happens.” The registered manager was passionate about the work they were doing and showed a particular interest when it came to people with a diagnosis of dementia who are at more advanced stages.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.A culture of openness enabled staff to raise concerns without fear. Leaders responded constructively to feedback and encouraged honest communication. People and staff said they could raise concerns without fear and that any problems were addressed promptly. Policies and procedures were in place to support staff in speaking up and raising concerns. The registered manager said, “I bring it up in supervisions. I am open and transparent, and staff know there is nothing to fear. We make it clear that there is always someone to talk to.” This meant people were supported by a team that felt confident to raise concerns.
 

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. There was an inclusive and fair culture with equality and equity for staff. Staff were treated fairly and supported within an inclusive working environment. The service valued diversity and promoted equal opportunities. Staff promoted inclusion and supported people in a way that respected their identities and protected characteristics. The service respected staff’s religious beliefs and made adjustments so they could practise their religion.

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 registered manager had limited computer skills, and the deputy manager routinely completed electronic tasks on their behalf. The deputy manager also worked in the kitchen at times, which further reduced their capacity to support managerial functions. As a result, most systems remained paper‑based, including care plans, daily notes and audits. While audits and reviews were being carried out, they often lacked the necessary depth to identify key risks. In several instances, audits failed to detect concerns later identified by the inspection team. Where concerns had been noted, they were not consistently addressed or followed up with appropriate action. For example, with a hot water tap which had been recorded in 2023 as being too hot. This indicated a lack of effective quality assurance and oversight. There was no evidence of audits for the daily checks the management team told us they were doing. Therefore, we were unable to see if the management team had previously identified some of the concerns we found during our assessment. We found errors in some documents which had not previously been identified. For example, the statement of purpose for the service was very brief and did not contain necessary detail.

Although a matrix for staff training was in place, there was a lack of oversight to ensure staff had the right skills and knowledge to carry out their roles safely. We found there were many gaps in the records provided to us used to keep track of staff training. For example, most night staff had no current first aid training listed. This meant people were supported by staff who may not have had the necessary training. Similarly records failed to evidence if staff had been safely recruited.We identified concerns with employment records, training records, recruitment files, daily notes, overall management oversight, and people’s environment which placed people at risk of harm. These concerns represented breaches of safe care and treatment and good governance.The registered manager had started to introduce improvements following our assessment. They were committed to ongoing service development, which was demonstrated during the assessment process with timely responses to the concerns identified.
 

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 the management team were open and transparent, and they collaborated with all relevant external stakeholders and agencies. The provider worked in partnership with health and social care professionals to achieve good outcomes for people. Staff and managers ensured that where needed, timely and appropriate referrals were made to health and social care professionals. External agencies told us they had no concerns about the service. Staff at the service ensured people maintained links with community services which were important to them. Families were encouraged to visit and join in with activities.
 

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, and effective practice. Concerns identified did not always lead to continuous improvement and sharing of learning across the home. Audits lacked detail and therefore failed to identify key risks and drive improvement. The service also did not maintain a record of complaints or learning from incidents, meaning there was no structured system to drive improvement or learn from concerns.

However, relatives commented that they had seen improvements happening prior to our visit, for example with new carpets and flooring. One relative said, “It’s not the best home in terms of furnishings, but the people are wonderful, which is what’s important. They have made lots of improvements to the furniture and flooring and it is nicer now than it was two years ago. It’s very well run and I couldn’t find a better situation for [relative]. I would recommend the place to anybody.” The management team were responsive to our findings and were open to feedback and demonstrated they wished to make improvements at the home to improve people’s experience whilst living there.