Little Sisters of the Poor - St Peters Residence

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 breach of legal regulation in relation to governance arrangements at the service.

This service scored 62 (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 told us, “As a Catholic care home run by Little Sisters of the Poor, St Peters places particular importance on community, dignity, spiritual life, hospitality and the personal needs of each resident.”

Feedback from people, staff and volunteers showed these values were understood and shared by everyone. Feedback from people included, “I think they do a marvellous job” and “I am extremely happy with [family member’s] care, and I am very grateful to the whole team at St Peters for the effort they put into making my [family member] safe and cared for.”

Many people told us they valued being part of the spiritual community. Comments included, “My [family member] takes great comfort from attending daily mass and rosary in the chapel as part of the community.”

Staff told us they felt proud of the culture of teamwork which within the home. Comments included, “St Peter's is a wonderful care home with a strong ethos of care and compassion. The residents are cared for in a family like atmosphere”and “I enjoy working at St Peter's because the atmosphere is so welcoming, the residents are well cared for, and each person is treated with dignity, respect and kindness.”

Leaders understood the context in which the provider delivered care and support. They embodied the culture and values of their workforce and organisation. Leaders were visible and approachable, and staff consistently described feeling supported by the management team. Comments from staff included, and “The Sisters provide a calm,cheerful and selfless service - not often found and a privilege to experience.”

Staff received consistent support through supervision, meetings and day‑to‑day contact with team leaders and managers. Staff also told us leaders were present and accessible and led the service by example. One member of staff said, “The registered manager is approachable and easy to talk to, and the deputy manager is also highly visible within the home.”

The provider fostered an open culture, where staff felt able to raise concerns and they were confident leaders would take the right action to resolve things. Staff felt they could speak up and that their voice would be heard. Staff told us they felt able to raise concerns informally and described an open‑door approach from managers. One staff member said, “We can speak up if we notice any problems or have new ideas.”

The provider strongly 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 management team demonstrated a clear and proactive commitment to supporting both people and staff with differing needs. The registered manager told us, “Our team members come from many different countries, bringing with them rich cultures traditions and stories. To honour this diversity and strengthen our sense of community we proudly celebrate a monthly Independence Day, dedicated to a country represented within our team.” Celebrations included music, dancing and sampling of the food from different countries and cultures.

Staff and volunteers from diverse backgrounds reported feeling highly respected and valued and they described leaders as fair, approachable and supportive. Staff’s spiritual needs were respected and celebrated regardless of their religious denomination. The service provided a prayer room during Ramadan for people of the Muslim faith and ensured staff who were fasting had regular breaks. One member of staff said, “Although the home has a Catholic foundation, there is no pressure on staff or residents to follow a particular religion, and individuals from different backgrounds are respected and supported.” The provider also actively made reasonable adjustments to support staff with disabilities and family commitments to fulfil their role.

Staff received diversity and inclusion training with particular emphasis on ensuring people from the LGBTQ+ community felt welcome. The deputy manager told us, “Staff training sessions have been conducted to ensure an accepting environment for LGBTQ+ residents and employees.”

Despite positive feedback from people, relatives and external partners, and some areas of good practice the provider did not always have robust systems and processes of good governance and oversight. The system of audits and checks of records were not effective in identifying shortfalls or managing risks, including in relation to the management of medicines, recruitment and the environment which were key shortfalls at the previous inspection.

Despite many positive examples of person-centred care and a culture where staff delivered kind and compassionate care the issues with governance created risks to safety, consistency and impacted the provider’s ability to assure safe and effective care. The provider started resolving many of the issues we identified during the inspection however, further improvements are required to ensure effective systems are in place and embedded to ensure people receive safe and effective care.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. The service had established positive working relationships with healthcare professionals, including GPs, pharmacists, community mental health teams and hospice services. There was a process in place to gather feedback from visiting professionals. Feedback was overall very positive.

Relatives told us staff communicated well and kept them up to date with key information. Comments included, “As next of kin I am kept well informed of [family member’s] health and if anything goes wrong” and “I get phone calls from the senior nursing team from time to time, and I’m regularly asked when visiting of how I feel my [family member] is doing.”

The provider actively fostered links with the local community to enhance people’s lives and build on the sense of community participation. One member of staff told us, “Local school children come to give concerts from time to time. We also hold Christmas and Summer Fairs which the local community attend and support.”

The provider did not always focus on proactive continuous learning, innovation and improvement across the organisation and local system. They did not always actively contribute to safe, effective practice and research.

Learning from key information was not consistent. Audits did not consistently identify risks and shortfalls, particularly in medicines management, recruitment and environmental safety which were key shortfalls at the previous inspection. Whilst leaders responded to the feedback provided as part of our assessment, they did not have effective systems in place to proactively identify and improve their practice.