Fosse Healthcare - St Mary's House

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 as good. At this assessment the rating has remained as 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 promoted a shared vision, strategy and culture that was underpinned by transparency, equality, fairness, human rights, diversity and inclusion. Leaders demonstrated a clear understanding of the challenges faced by people using the service and worked to ensure care delivery reflected the needs, preferences and aspirations of people and their local communities.

Feedback from people, relatives and staff consistently demonstrated the service had developed and embedded a positive, open and supportive culture. Everyone we spoke with was complimentary about the leadership and management of the service. One relative told us, “It’s a very well-run service and very nice people through and through.”

Systems were in place to support staff development and promote high-quality care. Staff received regular supervision, annual appraisals, competency assessments and opportunities to undertake additional training relevant to their roles. Staff spoke positively about working for the service and described feeling valued and supported by the management team. One staff member said, “I have a good rapport with seniors and managers. I am happy here. We have good training and you can always ask for help and have private conversations with them if you need to. I have good relationships with all staff at St Marys.”

The provider demonstrated a commitment to equality, diversity and human rights and worked in accordance with the Equality Act 2010. Where appropriate and in line with peoples expressed wishes and protected rights, recruitment practices considered the cultural, linguistic and personal preferences of people using the service. This enabled the provider to match care staff with people who shared similar backgrounds, cultures or languages when requested.

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.

All the feedback we received assured us the service delivered high-quality person-centred care. People’s preferences and wishes were considered first, maintained, and opportunities to make changes were offered. Staff reported a management regime which was considerate, understanding of its work force and provided additional support and flexibility where required.

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

People said they had no fear of speaking up if they needed to. One relative said, “I have no fear in raising concerns if I was unhappy with anything.”

Equally staff felt confident to speak up. One said, “We have free speech. We have a speak up policy and the whistleblowing policy too.”

Staff confirmed they had been trained in and how to ‘whistleblow’ and had access to the provider’s policy. They knew which key organisations they could contact to raise concerns if they felt managers were not taking these seriously.

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 provider demonstrated valuing diversity within its workforce and promoting an inclusive, equitable, and supportive working environment. Staff felt respected, valued, and able to contribute regardless of their background or personal circumstances.

The registered manager treated staff fairly. Staff described a positive culture where they were listened to, supported, and encouraged to raise concerns or discuss individual needs without fear of discrimination.

Managers provided support to staff when personal circumstances affected their working arrangements. This included offering flexibility to attend medical appointments, balance caring responsibilities, and meet cultural or religious needs.

The registered manager demonstrated a clear understanding of their role and responsibilities and was committed to ensuring the service was operated safely, effectively, and in accordance with regulatory requirements.

Robust quality assurance systems were embedded within the service and included a range of audits and monitoring processes to assess performance, identify areas for improvement, and drive continuous development.

The registered manager demonstrated a good understanding of their responsibilities under the Duty of Candour and was aware of their legal obligation to submit statutory notifications to the Care Quality Commission and other relevant agencies when required.

During the inspection, we identified 1 incident involving an accidental injury to a person which should have been notified to CQC but had not been submitted. We discussed this with the registered manager, who was open and transparent about the omission and took immediate steps to address it. They explained a manager had assessed the injury as not meeting the threshold for CQC notification at the time, although the incident had been appropriately reported to the local authority. The notification was submitted retrospectively, and the provider used this as a learning opportunity to strengthen oversight arrangements. An additional review process was introduced to ensure all injuries are routinely assessed against notification requirements. We undertook a review of historical incidents and accidents, which confirmed all other notifiable events had been reported appropriately. This demonstrated a positive approach to learning, accountability, and continuous improvement.

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.

A manager shared their partnership working approach and arrangements of how they work in close partnership with external professionals to ensure people are continued to be supported safely with any changes to their support needs from additional or emerging health and social care needs. These arrangements support staff to understand additional support the person may require and how this is to be followed to continue to maintain their needs safely and in turn their independence as much as possible.

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. Investment in a new electronic care record system had been made. Feedback from staff identified this technology had improved recording care they delivered and enabled any missed care to be highlighted, or overdue calls. The system also enabled people’s preferences and wishes to be updated in the moment or any concerns they highlighted or were reported to them which managers were alerted to.