Maryville Care Home

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 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 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 provider had developed a vision document for the service which indicated that they provided care to “Promote a sense of belonging, respect difference and collaborate with others to deliver high quality care and support based on our deeply held values and vision.”

People and relatives were happy with the care provided by the service and felt it was well led. with their comments included, “It seems to be well run. I think on the whole, the care and support appears to be ok.” Staff felt they were supported and a staff member said, “I feel like we are like one big family here. We all want what is best for the residents and the home in general.”

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.

The registered manager was supported by a team which included a deputy manager, administrators, team leaders and nurses. Staff said they were supported by management. They want to help me grow and develop.” The provider had programmes for the development of senior staff in management roles. The provider had policies which identified current legislation and good practice, accessible by staff.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.The provider had procedures and processes for staff to raise any concerns which were discussed with staff. When asked about if they felt they were able to raise concerns staff members said, “This is whistleblowing. We are reminded of how to do that. There are posters. I know if I am not listened to then I can ring CQC, and “The managers encourage us to speak with them and to speak up.”

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 had policies in relation to staff recruitment and management to ensure staff were treated in line with legislation. The provider had a staff handbook which provided guidance on the policies and terms and conditions of employment. Staff were supported through regular supervision and team meetings. The provider worked with a health and social care skills academy as part of their recruitment process to identify and support possible new staff through the application process. This partnership supported potential new staff through the application process and helped identify suitable candidates for roles within the service.

The provider had quality assurance processes for the monitoring of the care provided but this was not always robust enough to indicate where improvements could be made.

The provider had a number of audits in place, but these were not always effective at identifying issues we found and where improvements were required. Risk assessments had been completed. However, audits carried out on them did not show the issue with guidance not been provided for staff relating to people’s medical conditions and the possible impact on their care. Staff were not always deployed appropriately to ensure people’s needs could be met in an appropriate manner. Audits had been carried out for infection prevention and control. However, they did not identify issues in relation to the storage of unpackaged continence products in people’s bedrooms or the use of a single food temperature probe across difference types of food. These gaps in the audit process meant that risks of contamination and cross-infection were not fully addressed. These issues were discussed with the registered manager, who provided an action plan for improvements.

The provider carried out additional audits and checks on medicines, fire safety, mattress and other equipment. There was a ‘resident of the day’ system where information related to a specific person was reviewed. Daily meetings with senior staff reviewed any care issues relating to people, lessons learned from investigations and if there were any visitors. The provider managed people’s information in line with data protection and information governance legislation. There was a contingency plan in place for the home to provide guidance of how to maintain care in the event of an emergency.

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.

Staff worked with a range of health and other professionals which included the GP, district nurses, advocates, social workers and local authorities. There was also engagement with health charities, adult education, nursery care services and universities involved in research projects.

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. They actively contributed to safe, effective practice and research.

The provider had policies and procedures which reflected current legislation and were reviewed regularly. Staff were supported to complete a range of training to maintain and develop their knowledge and skills. The deputy manager explained team leaders had started the training to become accredited as care home assistant practitioners. This is specialist training to enable staff to undertake advanced clinical and management duties to assist the nurses. Following an incident, accident, complaint or safeguarding concerns, actions for improvement were shared with the staff. Feedback from people and their relatives was actively sought to identify and implement possible improvements in care.