St Marys Chanterlands 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.

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. Staff consistently described a positive culture within the service and told staff worked to provide good care. A staff member said, “Staff genuinely care about the residents, work as a team, and understand the importance of safeguarding, infection prevention and providing good-quality care.”

The registered manager was relatively new to the post but had promoted an open culture in the service. Staff told us they could go to the registered manager at any time, and they were confident about their leadership and the direction the service was headed in. One staff member said, “I have no concerns about the service, things are already improving and [registered manager] is certainly streamlining things.”

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 onsite daily to support the service, offering guidance and leadership. Staff told us they felt supported in their roles and described the registered manager as "firm but fair" in their approach. Feedback about members of the leadership team was positive, with staff and professionals describing leaders as knowledgeable and competent. A professional said, “I have found the Team Leaders, Clinical Leads and Deputy managers all to be competent, knowledgeable and I trust them when discussing residents’ healthcare and making decisions in their best interest.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they felt able to raise concerns and where confident issues would be addressed appropriately. Staff meetings took place regularly and were arranged at different times to accommodate staff working different shifts, so all staff had the opportunity to speak up if needed.

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 supported staff to develop in their roles. Staff told us they enjoyed working at the service and felt supported by managers and colleagues. Staff feedback demonstrated a positive team culture where colleagues worked collaboratively and felt valued.

The provider had clear responsibilities, roles and systems of accountability. However, governance and oversight arrangements were not consistently effective in identifying and addressing all areas of risk and concerns, and further improvement was required.Systems were in place to monitor the quality and safety of the service, with some audits successfully identifying some of the concerns raised during the inspection. For example, gaps in repositioning records and poor documentation around nutrition had been highlighted. Action was being taken to address these through staff discussions, monitoring and improvements to practice. The provider demonstrated a willingness to learn and respond to issues as they were identified.

However, governance systems were not yet fully effective in identifying oversight across all areas of risk and safety. For example, audits did not identify that the use of safety equipment had not been recorded and it did not identify when staff incorrectly documented specialist recommendations around people diets.

While the management team had begun taking action to address the poor standard of records, improvements were not yet embedded at the time of inspection. Further work was needed to strengthen governance arrangements, expand audits to cover all high-risk areas, and ensure monitoring systems consistently identified, escalated and addressed concerns in a timely manner. The provider worked quickly to address these concerns, expanding auditing tools and addressing record quality with the staff. But more time was required to embed good record keeping practices and to ensure this was sustained.

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 provider worked in partnership with other organisations and professionals to help ensure people received coordinated care and support. Staff understood safeguarding processes and made referrals to external agencies when concerns arose. The service-maintained links with healthcare professionals and specialist services to support people's health needs. One professional said, “I feel we have come a long way together and continue to try and improve things all the time. Our regular meetings are evidence that the Care Home is keen to work collaboratively with us.”

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 registered manager and provider accepted guidance during the inspection to help learn and improve, acting quickly to implement new records to support safety in the service. There was evidence of continued improvement and review within the service and action plans were in place to show when issues had been identified and acted upon.

The provider invested into the service to help improve. Investment had been made with the purpose built care home environment and updated care planning system which would help improve the services recorded keeping as this embedded over time and use.