Maristow 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 good governance.

This service scored 62 (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.

Leaders told us they wanted the service to be a “natural home with no airs and graces, where people could be comfortable and relaxed.” They demonstrated a passion to ensure people received a good standard of care based on their rights and preferences.

Leaders told us these values and vision were initially shared with staff during their interview and induction, and regularly thereafter through discussions and role modelling. Leaders told us they always informed staff of any feedback the service received. They said this reinforced good practice but also valued staff’s contribution.

Staff told us there was an open culture and morale was good. They said this was enabled as leaders were visible and approachable, and encouraged them to share their views.

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.

Staff spoke highly of leaders and were complimentary about their knowledge, approach and support provided. They told us leaders were committed to the service, had a daily presence, and were always available out of hours for advice if needed.

Relatives were very positive about leaders. Specific comments included, “[Name of leader] is always here, and keeps a close eye on everything,” and “We have total confidence in them, they’re always welcoming and care about us too.”

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

Staff told us they knew how to raise a concern or report poor practice if needed. They were confident they would be listened to and their concern taken seriously. One staff member told us, “I would go higher if it was not sorted.”

Leaders told us they regularly asked for feedback and expected openness and honesty from staff. They said they looked at finding solutions together, to enhance the team approach and responsibility.

Information about whistleblowing was readily available for staff reference as 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.

Leaders had built a diverse staff team which was celebrated. This included different ages, genders and ethnicities. Staff told us they felt included and considered themselves part of the team. One staff member told us, “I came here with my family, and we wore our traditional dress for staff and residents. It was great fun. I feel very welcome here.” Staff did not have any concerns about discrimination in the workplace.

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.

Quality auditing processes were not effective in identifying shortfalls within the service. For example, environmental audits had not identified unsafe temperatures of the hot water, the risks associated with the urn or unsafe storage of hazardous substances. Other environmental audits were not always being completed accurately. This was because a bedroom audit identified window restrictors were in situ and electrical wall sockets were secure, but this this was not what we found. This meant leaders could not be assured their auditing processes were fit for purpose.

Leaders told us they had assessed the risk of people scalding themselves from the hot water or falling from a height. However, they had not done this on an individual basis, and the assessments were very out of date. This had not been identified and did not ensure people’s safety. There were no records to demonstrate staff had taken the temperature of the water before assisting a person to have a bath. Staff and leaders confirmed this was because they were not aware they should do it. This lack of knowledge did not evidence effective governance and increased the risk of a person sustaining significant harm.

An inspection by the Fire and Rescue Service had recently identified a wide range of fire safety works which needed to be addressed. This included obstructed and overgrown exit routes, and hinges on fire doors which did not comply with legislation. Leaders told us they had taken action to address all areas identified, but records did not clearly evidence this. For example, the provider had placed a tick against each shortfall, without any description of the work completed or timescale involved. Similarly, there was no action plan regarding the planned refurbishment to the environment. This did not ensure the works would be kept on track and completed in a timely manner.

Leaders were not aware of the level of bruising people had sustained or that appropriate reporting procedures had not been followed. This meant there were shortfalls in their systems, which did not ensure people’s safety.

Leaders told us they observed practice during the day and completed night checks. This was to speak with the night staff but also to monitor people’s night-time needs and care provision. However, they did not keep a record of the visits. This did not enable their findings or any improvements made, to be evidenced or potential themes or trends to be identified.

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.

Leaders told us they worked closely with a range of health and social care services to meet people’s needs. These links had been built up over the 15 years the service had been operating so were very established. Information within people’s care records demonstrated such consultations were a regular occurrence.

Leaders told us they had other contacts related to the building, and systems such as staff training. They attended meetings and management forums to gain knowledge and share experiences and liaised with community services such as the local community groups.

Partners did not raise any concerns about the service or the way they collaborated with them.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Systems were not effective in consistently ensuring ongoing learning and improvement. For example, audits were not always identifying shortfalls and systems did not ensure leaders were informed of all incident and accidents. This did not enable appropriate action to be taken or lessons to be learnt. Some management practice was also disorganised, which did not evidence effective systems. This included no clear action plan for the refurbishment of the environment or records of night visits undertaken. This did not enable regular review, and ongoing improvement.

However, leaders described the various options for the future strategic plans for the development of the service. These were receiving further consideration to ensure the best option was decided upon.