St Elmos

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 requires improvement. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

At our previous inspection, we identified a breach of Regulation 17 (Good Governance). At this inspection, we found sufficient improvements had been made and the provider was no longer in breach of this regulation.

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. We found the values of the organisation were clear and put people at the centre of their support and care. The management team had formed a positive team ethos. Staff told us it was a positive place to work. One staff member told us, “I feel supported in my role. Management take the time each morning to go round all the supporting staff and service users to ask if everything is okay and how the day is looking.”

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. We received mixed feedback from relatives regarding communication from the management team. One relative said, “Communication generally good when concerns are raised.” However, another relative said, “I would like regular updates, photographs and information about activities.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had a whistleblowing policy in place, we observed this document in the communal areas of the service and accessible for staff and people living in the service. Regular team meetings, supervisions and daily walkaround enabled staff to feedback to management and raise any concerns. One staff member told us, “I do feel supported in my role. Support is provided through supervision, training, team meetings, guidance from senior staff, and opportunities to discuss concerns.”

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. Systems and processes including meetings and staff supervisions promoted a listening culture and equality, and diversity were recognised and supported.

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 provider had effective systems in place to ensure there was clear oversight of the service. Regular audits and monitoring were carried out in key areas of the service such as medicines management and reporting of accidents and incidents. This enabled areas for improvement to be identified and acted upon in a timely manner.

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. Staff worked in partnership with health and social care professionals to ensure people had the best outcomes for their health and wellbeing.The provider understood their duty to share information and work in partnership with external professionals.

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. Staff recorded incidents and accidents. These were reviewed by the registered manager and action taken to prevent reoccurrence. Any lessons learnt were discussed in team meetings.