St Joseph's 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.

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.

The service was in breach of legal regulation in relation to governance at the service. 

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. 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 feedback from people, relatives and staff was very positive. The atmosphere on entering the service was welcoming and staff engaged with us positively. Staff we spoke with told us they enjoyed working at the service and felt they provided good care to people using the service. A staff member told us, “The managers are very approachable, and the managers door is always open.” Another staff member said, “I think the manager is really trying hard with staff morale- they organise things like bingo and quiz nights and a massage. They want to please everyone. Staff and residents have separate and combined events.”

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. However, further work was required to ensure the management team consistently identified concerns found during the inspection and strengthened oversight of medicines management and governance processes.

The management team knew people well and were committed to providing quality care. There was a clear and well-defined management structure, which included a registered manager and a deputy manager who also acted as the clinical lead. Nurses provided clinical support to people, ensuring their health needs were met promptly and appropriately.

The registered manager explained how the senior team remained up to date with best practice and innovations in care. They said, “We attend conferences and updates related to wound care. It empowers nurses to deliver the right care. We look at any innovations and implement them where appropriate. We also access external bite-sized training sessions to keep our knowledge current.” This approach demonstrated a proactive commitment to continuous learning and improvement, ensuring staff were equipped with the latest knowledge and skills to provide effective care.

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

Staff managed complaints processes effectively, and people knew who to speak with if they had a concern or complaint.

People and relatives were positive about the service. Comments included, “I would recommend them, it is friendly, staff are pretty good friendly”, “The manager is so helpful. I would recommend them, if I need care this is the right place for me, it is the care workers here they want to do this work and they are happy to do it and like it, they are doing it from the heart” and, “I would recommend them – you are looked after, I am very fortunate as I have got a big room – I feel settled.”

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 completed equality and diversity training, which helped reinforce the organisation’s commitment to inclusion. During the inspection, we observed a diverse staff team working collaboratively to deliver care. Staff consistently told us they were treated equally and felt valued by the management team. One staff member shared, “I feel supported and valued as a team member. Management is approachable, listens to concerns, and provides guidance when needed.” Another staff member said, “The management at St Joseph’s Nursing Home is approachable, supportive, and committed to maintaining a high standard of care. They provide clear guidance and encourage open communication among staff.”

These comments reflected a positive workplace culture where staff felt empowered, respected, and engaged.

Effective governance systems were not in place to ensure safety and quality concerns were identified and acted upon.

The provider had systems in place to monitor the quality of the service, but these systems were not always effective. Audits were carried out; however, they did not always identify and address shortfalls or areas for improvement. For example: Monitoring charts, such as repositioning and fluid intake records, did not consistently align with the targets set within care plans. Medicines reconciliation processes were not accurate or effective, meaning we could not be assured people were receiving their medicines as prescribed. Temperature records for medicine fridges and storage rooms contained gaps, creating potential risks for medicine safety. Checks on pressure-relieving equipment were insufficient to confirm equipment was fit for purpose.

The registered manager responded proactively to concerns raised during the inspection, but the provider’s internal checks and audits had not identified these issues. This showed governance systems needed strengthening to ensure staff identified and managed risks promptly and used robust quality assurance processes to drive continuous improvement. Following the assessment, the registered manager told us they had introduced additional checks.

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.

The service had developed partnerships with various organisations and the local community through end-of-life care, the local authority, and through good links with health professionals. A professional told us, “The home communicates effectively with me. I know who the manager, deputy manager and nurses are and they are all very approachable and will always assist me when I visit or telephone.” Another professional said, “All the nursing staff I have contact with seem competent, caring, capable and communicate effectively.”

The provider did not consistently focus on continuous learning, innovation, and improvement across the organisation and within the local system.

Further work was required to strengthen processes for identifying areas where improvements were needed, particularly in relation to risk management and governance. During the inspection, we found the management team had not identified several shortfalls within the service. This meant we could not be assured areas for improvement and opportunities for learning would always be recognised and addressed in a timely and effective manner.

A proactive approach to continuous improvement is essential to ensure risks are mitigated, governance systems remain robust, and best practice is embedded throughout the service. Without this, there is a risk issues may persist or reoccur, impacting the quality and safety of care provided.