Mary's 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 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 75 (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 worked in partnership with the local authority and other agencies such as social workers, GPs and commissioners. This helped to ensure care and support was up to date with current best practice in relation to people’s specific needs.

The registered manager and management team worked in a collaborative way with other agencies. A range of care professionals described the excellent working relationships the staff had promoted for the benefit of people who used the service. Comments from professionals included, "I’ve found staff to be helpful and wanting to work in a co-ordinated way with other health professionals,” and “They [managers] encourage a joint working approach with doctors and community nurses. They are involved in multidisciplinary meetings and give ideas to produce better outcomes for people living at Mary’s Home."

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 ethos, vision and values of the service were led by the provider, the registered manager and senior staff. People and staff told us the management team were very approachable. One person said, "The registered manager is very approachable. They often come round for a chat."

Staff shared the vision of the service to provide person-centred care and to put people first.People and professionals commented positively about the support provided.People received their care from a service that monitored standards and looked at how improvements could be made. The governance and improvement agenda were firmly embedded into all areas to improve service provision.

There were regular quality checks on care files, care logs, medicines records, staff files and other records. These were effective in identifying improvements needed, such as if there was an increase in numbers of falls or if staff training was due.

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

Staff knew where to find relevant policies to support them should they need to raise concerns formally. They knew they should speak with senior staff within the organisation to escalate issues if necessary.

The service had processes to support staff in speaking up and raising concerns. This included relevant policies in relation to safeguarding and whistleblowing.

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 fairly and felt all staff had equal opportunities. The management team told us they had an open-door policy. There was always a manager visible within the care home to ensure staff could raise anything if needed.

The provider had clear processes and procedures in place to ensure they were working in line with the required legislation and ensured people’s and staff human rights were met. Staff were fairly recruited and treated. Staff had completed training in equality, diversity, and inclusion.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The registered manager and the staff understood their roles and responsibilities in relation to assessing, monitoring and managing the quality and safety of the care provided. The registered manager told us they carried out regular safety and quality monitoring checks on staff working practices in the home. A member of staff told us, “Managers carry out regular checks on our working practices. These checks are constructive and help us ensure we maintain high standards of care.”

Internal audits checked people’s records to see that tasks were completed and well-managed. They covered staff training and support, administering prescribed medicines, and dealing with complaints and safeguarding incidents.

The outcome of all the audits and checks were routinely analysed which helped the provider to identify issues and learn lessons about what they could do better. The managers understood their responsibilities in relation to their regulatory requirements around notifiable incidents. Timely notifications were made to the CQC.

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.

People and relatives told us they were aware staff worked in partnership with other agencies to meet people’s needs. No one raised any concerns about access to other health services.

The management team told us they had a strong partnership with health professionals to ensure people’s needs were met such as the GP, district nursing team and pharmacist.

The provider had policies and procedures to ensure information was effectively shared with appropriate agencies. For example, with the Local Authority safeguarding team which had recently completed a visit, and the management team actioned all their recommendations and actions.

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 effective procedures in place regarding reporting and learning from when things went wrong. The registered manager told us they carried out regular checks of the quality and safety of people's care. This included checks of the environment and equipment used for people's care and checks of medicines and care plans. Regular checks were made of any accidents. They were also carried out for people's health and nutritional status and any related incidents, such as weight loss, infection or skin sores. This helped to identify any trends or patterns to inform any changes that may be needed to improve people's care.

The service’s development plans included actions that came from these audits, quality assurance processes and feedback. All action points had a target completion date and identified the staff member responsible for them. We noted this system had been effective in driving improvements, such as improving the mealtime experience.