St Mary's Continuing Care

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 changed to 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.

This service scored 61 (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. Staff spoke very highly of the registered manager and other staff; they spoke of a family feel to the home. Staff and management understood the importance of listening to the views of people and their relatives about the service. The provider worked with the staff team to build open and transparent relationships. People and their relatives had been provided with clear information on how to raise suggestions and concerns about the service.

The provider had inclusive leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. The registered manager and nominated individual were both visible at St Mary’s Continuing Care and transparent with us throughout the assessment timeframe. Despite the issues identified in this assessment the leaders were open and honest and had the experience and knowledge to lead effectively with integrity to make the improvements required.

Staff told us they knew about the service’s whistleblowing policy and knew how to raise concerns. Staff were also aware they could report and concerns directly to the Care Quality Commission and the local safeguarding team. There was a whistle blowing policy in place. Staff were informed about this as part of their induction. Staff could access the policy if needed at any time. People had information provided to them, this allowed them to know how to raise a concern and their right to speak up. People and their loved ones told us they knew how and where to raise any issues or complaints. Comments included, “I am confident to give feedback and raise any concerns if I have any” and “I feel confident to speak up if I had any concerns they would be addressed, the management are approachable and visible”.

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 had all received equality training, and most felt they were treated fairly and equally. Staff had made requests and held discussions identifying areas of work where they required additional support or adjustments. The registered manager told us they would always endeavour to provide support where required.

The provider did not have sufficient systems to assess, monitor and improve the quality and safety within the service. We found audits were completed by leaders but failed to identify gaps we found during our assessment. For example, shortfalls identified with medicines and up to date care records. This was a breach of Regulation 17, Good Governance. Following the inspection the registered manager and nominated individual provided evidence they were addressing the concerns highlighted in this assessment.

The provider understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborated for improvement. Although we had a small sample of feedback from partners, they did confirm the provider worked with them to develop and improve the care for people.

The registered manager understood the needs of people living at the home, including their individual circumstances. However, as highlighted in this assessment the provider had not alwayspicked up on the concerns highlighted throughout this report and did not have effective governance processes to ensure learning and improvement. From the concerns highlighted during this inspection no service user came to any harm.