St Mary's Nursing Home Margaret Street Stone

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.

The provider was previously in breach of the legal regulation in relation to overall governance. Improvements were found at this assessment and the provider was no longer in breach of this regulation.

This service scored 68 (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, supported by the registered manager, had a clear and shared vision for the home, which focused on putting people first. Their approach was built on strong values, including being open and honest, treating everyone fairly and equally, respecting human rights, embracing diversity and inclusion, listening to people, and understanding their individual needs and challenges.

The home's culture prioritised people’s needs, with staff communicating clearly and respectfully, empowering people to make their own choices and delivering care with kindness and consideration. One relative said, “The home checks everything with me that needs to be done. The care is 100%. I cannot fault the support. Sometimes I’ll ask them to do something, and they’ve already sorted it”.

The strong partnership between staff, people and their families helped ensure care was person centred and built on trust and mutual respect.

The provider’s inclusive leaders understood the care context and reflected the organisation’s culture and values.

The registered manager demonstrated a passion to provide good care and to support the staff to be the best they could be. Everyone spoke highly of the support they received from the registered manager. One staff member told us of the support they had been given during a difficult time with their personal circumstances.

Most people we spoke with told us they felt well cared for and treated with compassion and dignity. People knew who the registered manager was and felt able to talk to them. One person told us, “Yes, I know the registered manager, they often come round to see me”. Another person told us, “I know the registered manager, they are easy to talk to”.

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

Staff we spoke with knew the whistle blowing procedures and who they should report any concerns to [Whistleblowing in a care home refers to the act of reporting concerns about poor practice, neglect, abuse, or any wrongdoing that could compromise the safety or wellbeing of residents]. Staff shared that they felt confident any concerns raised with the registered manager would be addressed, and that, if they ever felt unheard, they knew how to seek support from an external agency.

Staff and people who used the service were encouraged to have their say in how the service was run. There were regular staff team and resident meetings where ideas for improvements were discussed. One person told us, “There are residents’ meetings to raise any concerns”.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for staff who worked for them.

The registered manager demonstrated a robust commitment to promoting diversity and inclusion, aligning with the Equality Act 2010. Staff’s individual protected characteristics were respected and celebrated. The registered manager fostered an inclusive workplace where LGBT+ staff felt safe, respected, and empowered to express their identities without fear of discrimination [LGBT+ is an acronym that represents people’s sexual orientation or gender identity]. Equality and diversity training was provided to staff to develop inclusive attitudes and practices to both people who used the service and their colleagues.

The provider had clear responsibilities, roles, systems of accountability and governance. The deputy manager completed a range of audits, monitoring the quality of care within the service. However, the existing systems did not consistently identify when care plans, risk assessments, and medication records required updates, or consolidate this information effectively to ensure staff had access to the most accurate details needed to support people. No one had come to harm and staff we spoke with knew people well and knew their needs. We also found that the monitoring of care tasks was not always effective. On the morning of the inspection, staff had not updated the handheld device used to record care for 1 individual. As a result, it appeared that their care needs had not been met for several hours; however, subsequent review confirmed that appropriate care had been provided. The system had not flagged to alert anyone. The deputy manager told us that this would be reviewed and rectified. Following the inspection, action was taken to update the records to ensure that all information was accurate, consistent, and reflective of individuals' current needs.

The provider clearly understood and carried out their duty to collaborate and worked in partnership, and services worked seamlessly for people. They always shared information and learning with partners and collaborated for improvement.

The registered manager demonstrated a strong commitment to partnership working by consistently sharing information and learning with external agencies. This approach ensured integrated, person-centred services that responded to individual needs and preferences. Staff worked well together, had access to training and resources, and were confident in providing quality care.

Although we found some of the issues found during the last inspection were still present in relation to medicine protocols, other improvements had been made. The registered manager continued to show a strong commitment to learning and improving. Staff worked together to find better ways to support people, both within the service and in the wider community. There was a clear focus on treating everyone fairly and delivering care that was personal, respectful, and helped people live well.

The registered manager belonged to several forums and external groups to remain up to date with best practice. Staff actively engaged in safe and effective practices and played a key role in this culture of development, with team members acting as champions in various areas of care. For, example, the oral care champion led by example, delivering training to colleagues to ensure effective and consistent support for individuals’ dental hygiene. As part of this commitment, staff successfully completed the ‘Care to Smile’ Programme, an initiative aligned with NICE guidance that enhances oral health provision in care homes through structured education and practical support. Their efforts in this area were recognised with an award, highlighting their dedication to improving residents’ wellbeing through specialised care.