St Martin's Residential and Nursing 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.

This is the first assessment for this newly registered service. This key question has been rated 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.

There was a positive and inclusive culture at the service. People, relatives, staff and external professionals felt the service was well run. People felt valued, listened to and included. A relative commented, “Communication is good throughout, they do a very good job communicating.” A professional told us, “All the residents seem to be happy.”

Staff explained they felt supported and enjoyed working at the service. Their comments included, “I enjoy working here” and “The management team are supportive and will help out.”

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.

There was visible and clear leadership in the service. Staff knew who to go to if they needed support to meet people’s needs, and told us the regional manager, registered manager and deputy manager were approachable, available and supportive. One person told us, “The staff are amazing, and I am very impressed with the cleaners and the maintenance man. They are all part of the team.”

The registered manager told us they felt supported by the provider and stated they had support from a range of different departments such as, the learning and development team and HR team. They commented, “There is a lot of support for me as registered manager”.

Relatives, staff and healthcare professionals were complimentary about the registered manager stating they addressed any concerns and acted on feedback quickly.

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

People told us they could speak up, and feedback from relatives echoed this. For example, 1 relative told us, “The manager is very good and transparent. [They are] always available to discuss issues to get to the bottom of them”. Another relative told us, “I value the experience of the staff as that is what has benefitted mum. It’s well led, and we have a really open relationship with the home.”

The provider had processes which supported people, relatives, and staff to speak up about any concerns within the organisation. The registered manager told us they welcomed residents, staff and visitors to raise concerns with them.

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 told us they were treated well and supported equally by the management team. The provider had processes to encourage an inclusive culture and optimise staff wellbeing. Any issues were discussed in handover, team meetings, supervisions or as they arose, because the management team were readily available and supportive with their staff.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

There were systems to support the registered manager to identify and address quality concerns and risks to the organisation, however, not all were effective in identifying shortfalls. For example, where there had been incidents of safeguarding, this had not always been reported to the local authority safeguarding team in a timely manner. Associated statutory notifications to CQC had not always been submitted in line with legal requirements.

Mental capacity assessments were not always decision specific. The provider told us this had been identified in July 2025, and assessments were being repeated to ensure these were completed in line with the legal framework. Whilst the registered manager had completed work to address this, in October 2025 a mental capacity assessment had been completed for 1 person in which several issues were discussed at once. This meant the actions to address the findings of the audit in July had not been embedded. The provider assured us they would work with the registered manager to address this.

Daily notes for 1 person lacked detail of the actions staff had taken to support the person. Audits had failed to identify this. However, we reviewed 2 further care plans which did contain detailed accounts.

The registered manager had undertaken quality checks which included health and safety, infection control, recruitment, and staff training. Outcomes from these audits were discussed and action plans developed to address the areas required. For example, dining chairs that were damaged had been reported and approval gained to replace these.

The provider had oversight of the auditing process to ensure all identified actions were completed and signed off.

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.

There were effective processes to ensure partnership working with people, relatives and health professionals was maintained to improve people's experiences, health, and wellbeing. The registered manager told us, “We work closely with health professionals.”

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.

Leaders ensured they continued to learn and improve their services. Best practice and examples of what had worked well were shared amongst the team and during the monthly managers meetings. The registered manager told us they received regular updates from the executive team which was shared.

The management team were keen to continue to build on positive relationships with partner agencies. Staff and a health care professional told us the service had improved and “there is a clear focus on ensuring safety”.