Mary House

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 changed to 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.

The registered manager had a clear vision of the future and direction of the service which put people at the centre of any development, changes or improvements. The registered manager acknowledged the need for continuous improvement and learning and how this shaped the future of the care and support provided.

Staff spoke to us about the vision and culture of the service. Staff said that the management team were approachable and keen to listen, and that they feel well supported. They said that things had improved and felt the home was definitely going in a good direction. The registered manager and staff understood and supported people’s (and staffs’) cultural and spiritual needs. People were treated equally, and their individual needs were met in line with their preferences. The management team knew people well and also worked alongside staff to support and promote good practice. All the staff were positive and proud of the care delivered to people who lived at Mary House. Staff told us, “Best job, I love working here.”
Feedback from staff was consistently positive and enthusiastic when we spoke with them. The service aimed to give people consistently good care and staff worked together to try and achieve this. Individual staff supervision and group team meetings were used by the provider to remind staff about their organisations underlying core values and principles.

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.

Staff told us that management team were approachable, ‘real’ and will listen. Comments included, “Always come on to the floor to check in with us all, see the residents,” and will help out if needed, talk to us about changes, or appointments so we are aware,” and “Manager has worked here for a long time, as a carer, so knows the challenges, and is very pro-active.”

The senior management team was committed to improvement and was open and transparent regarding the improvements made and those that were on going. We were told that the focus of the service was to ensure people were safe and happy, and that any learning was taken forward positively. The registered manager was proud of the staff and of the improvements made, and ensured he always thanked his staff team.

There were systems and processes in place to support staff development and progression within their roles. They talked of how they were supported to gain qualifications and to consider extending their role, Senior care staff were supported to be become medicine givers and received support and training. Regular supervisions, spot checks, competencies and values-based supervisions took place. The provider’s senior management visited the home regularly and provided support and supervision to the registered manager, who confirmed she attended organisational manager meetings which enabled learning across the organisation to be shared, and relevant lessons learnt implemented within the home. The provider supported staff to attend external training, conferences and meet with other providers and managers to network through various forums.

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

Staff told us that felt able to raise concerns. One staff member said, “If I had a concern, I would go to manager, or deputy manager, if I didn’t think it was being taken seriously, I would go to the local authority, and CQC,” and “We all get training in safeguarding, we also know how to whistleblow.”

The provider and registered manager understood their responsibilities under the duty of candour. The Duty of Candour is to be open and honest when untoward events occur.

We have received notifications as required.

During our assessment we found that the management team were open and transparent. They admitted when things had gone wrong and demonstrated how they had used these to make improvements. They told us of the work they had done to improve and meet breaches of regulation from the last inspection.

Staff were supported and enabled to voice their views and concerns. They were aware of the whistle blowing policy but felt that they could raise them and be listened to. The provider had up-to-date whistleblowing policies and procedures which were in line with current guidance. People and their relatives confirmed they knew how to complain, and a copy of the complaints policy was available in the home and on the service website. Relatives told us; they would make a complaint if they needed to but would talk to staff first. A record of complaints was held in the service. These included the information on the complaint and how this was responded to. We saw complaints had been responded to and actions taken as necessary.

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

The registered manager encouraged and supported open communication and there was an open-door policy. The home was proud to be inclusive and supported both staff and people that used the service. The registered manager said the staff team was multicultural and everyone was respectful of each other.
The provider had procedures in place to promote staff well-being and worked to provide flexible working conditions if required. There were robust measures in place to monitor, maintain and promote good mental well-being across the staff group. There was a formal recruitment process and equality, diversity and inclusion policy in place to guide equitable and fair recruitment and selection procedures. Staff were encouraged to undertake training in equality and diversity.

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.

Quality assurance systems were in place and had been used effectively to consistently improve the service. The management team had worked hard to ensure there was robust oversight and effective governance at the service. There were still areas to improve, and this was acknowledged by the management team. For example, improving daily logs documenting, improving and simplifying training overview.

There were computerised systems and processes to assess, monitor and improve the quality and safety of the service provided. Governance meetings were held regularly and minuted. These were used to monitor effectively and pick up trends/concerns early.

Staff told us about their duties and responsibilities; they told us how they managed risk and reported concerns to management. Managers and staff understood their roles, and were clear about quality performance, risks and regulatory requirements. There were checks and audits in place to monitor quality and safety. Action was taken when audits identified areas for improvement.

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.

This included using services such as advocates, physiotherapists, chiropodists and specialist teams. One external stakeholder told, “Very interesting service -complex in all ways but staff are very knowledgeable, pleasure to work with.” Another said, “Lovely place to come to, staff are polite, I have no issues with this home, a manager or a senior will always greet me, to answer any queries and to give me accurate update on the reason for my visit.”

External performers were booked to provide entertainment to people, and trips out happened regularly with designated drivers.

Trips were arranged to match with people’s hobbies and interests, such as gardening, parks, feeding ducks, and local places of interest. At staff and relative meetings activities were discussed and comments noted and taken forward.

Staff said they have good relationships with other health professionals, and one staff told us, “Health professional are really helpful, we can contact and even if they don’t visit, they will contact us, I think together we get good outcomes for people.” The registered manager said that people were part of their local community. They also said, “We are arranging trips out to local venues.”

Health professionals told us that they have a good relationship with the service and staff work with them in a professional and knowledgeable way.

The registered manager and provider were proactive in building relationships with other organisations and into the local community to improve outcomes for people. They had close links with the local authority and utilised any additional training opportunities when they were offered.

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.

People and their relatives had opportunities to feedback their views about the service and quality of the care they received. People and relatives all described the staff and management of the service as open and approachable. Staff supported people to give feedback and opportunities which they had to drive improvements and encourage learning from any incidents which occurred. The provider and registered manager had oversight of accidents and incidents. Trends and patterns were identified and addressed. We saw example of lessons learnt following incidents which occurred within the service. For example, improved technology to monitor and identify seizure movement whilst in bed. Complaints were taken seriously and learning from them taken forward. We viewed complaints and saw that they were responded to in a timely way and where required, training to improve was undertaken. Reflective meetings were held with staff to give opportunities to discuss development points to encourage improvement in practice. Learning was, where appropriate, also shared across the providers other services. The registered manager encouraged staff to speak up about positive ideas.