St Mary's Residential 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.

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 61 (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 staff team were aware of the work required in the development of the service with local authority involvement. Staff we spoke with felt inclusive of the changes being made. One staff member told us, “We want to get better and make these changes, I think we are improving.”

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

The leadership team had failed to demonstrate effective oversight of their responsibilities. For example, they failed to act on environmental risks ensuring risk assessments were in place for the use of stair gates on communal stairs, gas cylinders were not being stored safely outside the service, not ensuring an investigation and safeguarding referral was made for unexplained bruising, and oversight of people’s care needs were not being met regarding repositioning.

However, the leadership team were proactive with concerns we raised, and these had been actioned or were being actioned by the end of our inspection.

The new manager joined the service towards the end of our assessment.

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

The provider had a whistle blowing policy in place and staff felt confident to talk to the leadership team at the service.

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.

All staff completed equality and diversity training and understood the importance of treating colleagues and people with respect.

There were no reports of bullying or discrimination, staff said they felt valued and supported.

The provider did not have effective governance systems in place to assure themselves of the quality and safety of care provided to people. Audit and quality assurance of key areas of service provision did not identify concerns we found during the assessment. This meant issues were not always followed up, rectified and monitored appropriately to drive continuous improvements. For example, the provider had not identified the concerns we found, through their audit system or demonstrated appropriate action had been taken.

The provider responded promptly when issues were brought to their attention and provided evidence of improvements made.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider did not have good links with the local community; people did not get the opportunity to access their community. One relative told us, “There could be better links with the local community. The home is very isolated.”

However, the provider worked closely with the local GP and District Nurse teams. During our inspection we saw healthcare professionals visit the service to support people.

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.

The provider lacked effective systems to check on the quality of people’s care, ensure lessons were learnt and improvements identified. However, the provider had an action plan with the local authority and was working on developing systems which would provide oversight and opportunities for learning, innovation and improvements across the service.