Saint Jude 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 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 requires improvement. At this assessment the rating has remained 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 provider was in breach of legal regulation in relation to good governance.

This service scored 50 (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 did not always have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. For example, although some values and positive intentions were evident and the registered manager described areas they believed required improvement, the overall direction was not embedded or understood by staff. The registered manager acknowledged issues with paperwork, with most care plans and risk assessments requiring review. They outlined an action plan to stabilise the staff team and put systems in place for reviewing care plans and supporting staff learning and development.
A period of instability, caused by several changes in management over recent years, had clearly affected staff culture and hindered the providers ability to make the necessary improvements.
 

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty. For example, it was evident the registered manager's capacity was stretched due to ongoing challenges in recruiting care staff, which limited the time they could dedicate to strategic oversight and embedding improvements. Some staff told us morale was low and they did not always have clear expectations or consistent guidance in their roles. This suggested communication structures were not fully effective. Leaders had insight into the pressures within the service, but the lack of a stable and fully staffed team meant they were not always able to model or sustain a positive, inclusive culture. This impacted their ability to ensure staff felt valued, and confident in their responsibilities.
However, the provider and registered manager had a visible and active presence in the home and were supported by team leaders and administrative staff. The registered manager had extensive experience and demonstrated a clear commitment to driving improvements.
 

People did not always feel they could speak up and that their voice would be heard. For example, some staff told us the provider’s presence made them feel uneasy and they did not find them approachable. They described the atmosphere within the service as changing quickly when the provider was around, which reduced their confidence to speak up. Although policies were in place to support staff in raising concerns, this feedback indicated the culture did not always support staff to do so in practice.
Feedback from family members was mixed. Some family members told us they had experienced difficulties in getting a response from the provider. However, some family members reported when they raised concerns, the provider responded well. One family member told us, “Anything we've asked about, they’re on top of it.”
Other family members described the provider as helpful and said they were able to contact them directly. Staff told us they received regular supervision and felt able to raise concerns within these sessions.
 

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. For example, there was a diverse workforce at the home, and it was clear staff worked well together as a team. One staff member explained they had been supported with flexible working arrangement to accommodate their personal circumstances. Staff completed equality and diversity training as part of their mandatory induction to support their understanding of inclusive practice.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or
share this securely with others when appropriate.
Governance systems were not effective in ensuring sufficient oversight of the care being delivered. We identified concerns in key areas including medicines management, care records and cleanliness which had not been detected through the provider’s own monitoring processes. When these concerns were raised with management on day one of our inspection, actions remained outstanding on day two, indicating a lack of timely and responsive action from the provider. When asked to provide evidence of managerial audits, the provider was only able to produce a small number of nighttime spot checks. These were limited in scope and did not provide adequate assurance about people’s safety or the overall quality of care.
The registered manager had developed an action plan to address areas requiring improvement; however, these had not yet been embedded into day‑to‑day practice. The provider was unable to explain significant gaps in staff training compliance, posing a risk to people being cared for by staff who may not have the necessary skills or up‑to‑date knowledge.
Daily care records were not always completed in a way that demonstrated appropriate monitoring of people’s health needs. This was despite an internal process requiring team leaders to review staff recordings each day. Concerns were raised with the registered manager that daily notes suggested people were not being offered adequate food and fluids; the registered manager told us this was due to staff failing to record what had been provided. Inconsistent or incomplete records meant leaders could not be assured people’s needs were being met.
A staff member explained daily walkaround sheets were primarily used to delegate tasks and did not include any meaningful oversight or auditing of care practices. This demonstrated governance systems were not operating effectively or driving sustained improvement. Care plan reviews were insufficiently robust, with discrepancies noted between different sections of people’s plans.
 

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. For example, managers and staff worked closely with healthcare professionals and external agencies. Staff made timely referrals to the district nursing team, GP and other services when people required additional support. Feedback from these partners indicated staff acted promptly when new concerns were identified and worked collaboratively to support treatment plans. Where people needed new equipment, this was arranged without delay, helping ensure their needs were met safely. Family members told us they felt welcomed within the home, with one saying, “There are no restrictions on visits,” which supported people to maintain relationships and remain connected to their community.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research. For example, although efforts were being made to embed new practices, update systems and promote wellbeing, progress was hindered by an unstable care team and ongoing recruitment challenges. Improvements tended to be reactive rather than proactive, and staff reported lacking guidance and skills to think creatively to help people make progress or maintain their health. The provider did not always demonstrate effective learning from incidents or day‑to‑day practice, and staff reported feeling hindered because of insufficient training on the care planning system used to record daily interactions with people. This limited the providers capacity to improve and prevented learning from being translated into better outcomes for people.