St Marks Court

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 remained 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.

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.

Following a period of instability, leaders focused on improving consistency and standards. Leaders were open about matters that needed to improve and encouraged staff to reflect on mistakes without attributing blame. One staff member described a better feeling in the home now a permanent manager was in place. The Statement of Purpose contained inconsistent information about the service’s capacity, which the provider corrected after CQC raised this.

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.

Leaders were visible within the service and understood many of the service’s risks and priorities. Regular walkarounds and flash meetings were completed, and regional oversight supported the service during changes in leadership. Staff feedback about leadership included positive comments about the support available.

However, leaders had not ensured all staff one-to-one meetings and wellbeing checks were completed, and some care and assurance records remained inaccurate, inconsistent or incomplete. This reduced assurance that management oversight was consistently effective.

People did not always feel they could speak up and that their voice would be heard.

The provider had arrangements for people and staff to raise concerns, including meetings, surveys, one-to-one discussions and whistleblowing procedures. Feedback was mixed. Some staff felt able to raise concerns and there was evidence that concerns had been acted on.

However, other staff said they did not feel safe raising concerns or were not confident that concerns raised would be resolved. This reduced assurance that all staff felt able to speak up and that their concerns would be heard and acted on.

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.

The provider had policies, training and recruitment processes intended to promote equality, diversity and inclusion. Staff could request reasonable adjustments, and leaders understood their responsibilities to promote fair and inclusive employment practices.

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.

Local, regional and organisation-wide governance systems were in place and identified many of the concerns found during the assessment. However, issues with medicines, care records and audits recurred after leaders had identified actions, and some assurance information contained inaccurate or inconsistent data. Mental capacity and best-interests records, personal emergency evacuation plans and some electronic care records also contained contradictory or incomplete information. Managers identified and discussed concerns, but did not always demonstrate that resulting actions were effective and sustained.

This reduced assurance that identified improvements were consistently implemented and embedded in practice.

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.

The provider worked with specialist health services, commissioners, advocates, faith groups and community organisations. Staff shared relevant information with partners and acted on professional advice. Community outings, visiting performers, church services and veteran-related links helped people maintain connections outside the home. A relative told us, “GPs and other professionals are involved when needed and staff follow things up.”

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.

Leaders used feedback, incidents, complaints and audits to identify improvements, and staff shared learning through flash meetings and staff meetings. The service also explored different approaches to improving people’s experiences, including veteran-related work, involving people in recruitment and a falls-prevention initiative.

However, some improvements were not consistently embedded. For example, medicines fridge security and temperature-monitoring issues were identified and actioned but were found again during later checks. Care-record documentation issues also continued to be identified through audits and the assessment. This showed learning did not always result in sustained improvement.