St Margarets 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 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 75 (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.

Relatives were confident staff were kind and praised the service’s compassionate culture. One relative said, “I think [My relative] is getting the best care [they] can” and professionals comments included, “Generally there’s a lovely atmosphere and people look well looked after”.

Staff recognised improvements had been made since our last assessment. They told us things were more organised and this had impacted positively on the quality of support they were able to provide. Staff comments included, “There have been lots of changes since you were here, everyone is working more together, and we are on it. You don’t feel you are the only one doing what you should be doing” “It is a lot better, more paper and more intense, but it is ok” and “The staff morale is brilliant, it is a great place to work”.

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.

The service was led by a registered manager whose role and responsibilities were well defined and understood by staff, people using the service and their relatives. The registered manager was supported by a clinical lead and a small group of team leaders who had been asked to take on additional responsibilities since the last assessment. Team leaders had responsibility for completing specific audits and checks to support the registered manager. A team leader told us, “Now I am in charge of getting all the weights done and I am the oral care champion. I do oral care assessments and once a month update the information and after any dental appointments”.

In addition, the provider’s directors continued to visit regularly to support the registered manager, provide advice and ensure any issues reported were promptly addressed. The registered manager told us, “There is a lot more recording going on than there was” and “The Director is in most days”.

People and their relatives were constantly complementary of the registered manager’s approach and told us, “The manager is lovely, we have a good relationship. [They] are proactive and any issues are dealt with quickly” and “[The registered manager] is very good, excellent”.

Staff reported they were well supported by the registered manager who was approachable, listened and acted upon any issues they raised. Staff comments included, “The managers are brilliant. I have seen improvements since last inspection. The registered manager puts in a lot of hours”, “I could never fault [the registered manager] anyway, as a manager they tick all the boxes. The door is always open and [the registered manager] is there for you” and “The managers have firmed up since you were last here. Now we are told this is the way it is going to be, which I think we need”.

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

Relatives told us the service communicated effectively and they were kept updated when people’s needs changed. We observed relatives were confident approaching the registered manager to ask questions, discuss any issues and gain feedback on how their relative was before visiting.

Staff were well supported and received regular supervision. Team meetings were held regularly and provided additional opportunities for staff to discuss issues, suggest changes to practices and share learning. Staff meeting minutes showed the registered manager listening to and acting upon staff feedback.

Professionals were confident raising issues with the registered manager and told us, “We have no concerns, if we did, we feel we can report [to the registered manager] and they would be addressed”.

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 valued and their requests for flexible working patterns had been approved wherever possible. Staff told us, “I start after the school run”, “It is good here, they have supported me moving to part time, they were good as gold” and “I could not wish for a better manager”.

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.

Governance systems had significantly improved and were now effective in ensuring compliance with the requirements of the regulations. People’s care plans now accurately reflected their current needs and known risks had been effectively mitigated. Necessary DoLS applications had been made and decisions made on behalf of individuals who lacked capacity had been consistently made in their best interests. The registered manager told us, “Audits are all up to date, we do loads more audits that there was. Everything that was picked up has been completed.”

In addition, records were noticeably more organised, and the registered manager and clinical staff were able to find information when requested. Necessary notifications had been submitted to the Care Quality Commission as required.

Staff now received regular supervision and told us they were well supported by the registered manager. Staff told us, “They’ve done spot checks on staff performance and appearance” and “[The registered manager] has knuckled down since [you visited] and things have improved”. Additional systems had been introduced to support clinical staff and plans developed to ensure the service had ongoing access to clinical leadership.

Team meetings and residents meetings were now held regularly to gather feedback on people’s experiences, discuss proposed changes and identify any areas of further improvement. Minutes of these meetings showed suggestions made had been listened to and acted upon.

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 service worked with local health system partners collaboratively and effectively. Prompt referrals were made and advice provided acted upon. Professionals recognised the service’s performance had improved since the last inspection and their comments included, “It seems all right. I have never seen anything I am concerned about” and “I think the staff are really lovely and they are always up to something with people”.

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.

The provider, registered manager and staff team had engaged positively with the assessment process and had taken action to address the issues raised at our previous assessment. They had engaged positively with the local authority and acted on advice and guidance provided. Staff told us, “It’s a lot better now” and “I think you coming in has done us a favour. You can certainly see the improvements. With everything having improved you do feel better, now we on the other side and on the up.”