St Andrews

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 as good. At this assessment the rating has remained as 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.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider did not always operate effective governance systems to identify, monitor and provide assurance that risks to people's health, safety and wellbeing were effectively managed.

The provider's governance systems had not identified several concerns we found during our assessment. Environmental monitoring had not identified unsecured wardrobes, unstable garden steps or the unsafe storage of hazardous substances. Infection prevention and control audits had not identified concerns relating to clinical waste storage, mouldy food stored within an accessible refrigerator or staff infection prevention and control practice. In addition, the associated health and safety and infection prevention and control risk assessments did not fully reflect the environmental and infection prevention and control risks we identified during our assessment.

The registered manager explained weekly health and safety checks had been completed on the live electronic care record system and that information displayed differently when reports were exported. They confirmed they had raised this issue with the software provider. However, the records available during our assessment did not provide assurance that these environmental risks had been identified through routine governance processes before our inspection.

The provider's medicines governance arrangements did not always provide effective oversight. The registered manager explained they relied on electronic prompts within the care record system to support staff to administer time-specific medicines and on staff reporting any delays. Medicines Administration Records (MARs) confirmed medicines had been administered during the correct medicines round but did not record the exact administration time.

The registered manager explained recorded times reflected when stock balance checks were completed rather than when medicines were administered. The provider's medicines audit had not identified this recording issue. As a result, the governance systems and records available during our assessment did not provide sufficient assurance that documentation accurately reflected the administration of time-specific medicines.

Governance arrangements were effective in other areas. The registered manager understood their regulatory responsibilities and had submitted statutory notifications where required. Staff consistently described leaders as visible, approachable and supportive. People and relatives also spoke positively about the leadership of the service. During our assessment, we observed the registered manager interacting positively with people, seeking consent, respecting privacy and adapting their communication to meet people's individual needs.

The registered manager responded promptly to the concerns identified during our assessment. They addressed the environmental risks, strengthened infection prevention and control arrangements, reinforced medicines recording expectations with staff, introduced additional monitoring arrangements and escalated concerns regarding exported governance reports to the electronic care record provider. These actions demonstrated a commitment to learning and continuous improvement.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.