St Michaels

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 remained 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 promoted a culture of openness, respect and continuous improvement. Staff were aware of and shared the provider’s vision for the service which was based on valuing and respecting people. A member of staff described the culture within the service as ‘family like’, adding, “We are always trying to do better for people.”

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.

The registered manager knew people and staff well and supported them as individuals. One person pointed out the registered manager and said, “That’s her, we like a good chat with her about how things are here and she listens.” Staff told us the registered manager and senior staff were available for support and advice whenever they needed it. A member of staff described leadership within the service as ‘very good’.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. People and their relatives told us they felt able to speak up or raise any issues they had. They said they were confident the registered manager and staff would listen to them and take any actions needed to resolve issues.

The provider had a whistle blowing policy that staff were aware of. Staff told us there was a positive and open approach to speaking up in the service and they were assured they would be listened to. One staff member told us how responsive senior staff and the registered manager had been when they had raised 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. The registered manager supported staff to balance their work and home life where needed to help support their wellbeing.

The provider had clear responsibilities, roles, systems of accountability and good governance. Most audits carried out by the registered manager had been effective in highlighting and resolving issues. However, audits had not identified discrepancies in medicine stock balances and where relative’s input had not always been recorded in best interest decision records. During this assessment the registered manager took action to resolve the issues highlighted and reviewed audit processes to ensure the issues did not occur in the future.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. This included improvements in the use of technology within the service. An electronic medicines management system was already in use and moving care records to an electronic system was in progress. This meant staff could access information more easily and complete records in a more timely and efficient way. We saw examples of learning from audits which had driven improvements, such as a reduction in people experiencing falls.

Staff told us the registered manager encouraged learning from things that went well in addition to things that did not go so well. They said information from staff, people and relative’s meetings helped identify where improvements could be made to enhance people’s experience of care.