St Marys

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-led 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 outstanding. This meant service leadership was exceptional and distinctive. Leaders and the culture they created drove and improved high-quality, person-led care.

This service scored 93 (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 clear, well‑embedded vision and culture based on transparency, equity, human rights and inclusion. Leaders showed an exceptional understanding of people’s needs and used this to deliver consistently high‑quality, preventative and person‑centred care. The registered manager and staff worked effectively with external professionals in line with the provider’s wider strategy.

The service had an exceptionally positive, inclusive culture. People, relatives, staff and professionals consistently described St Marys as open, welcoming and fully focused on people’s needs. Staff embodied the provider’s values and worked collaboratively to achieve outstanding outcomes.

The registered manager was a dynamic and compassionate leader with a deep understanding of each person’s needs, preferences and life history. Their person‑centred leadership ensured people remained at the heart of all decisions.

Staff spoke passionately about making a difference. One told us, “We want everyone who lives here to live their life to the full, and we want to help them do that.”

People, relatives, staff and professionals had regular opportunities to share their views. The registered manager acted on feedback transparently and communicated improvements clearly. Equality, diversity and human rights principles were fully embedded and understood by staff, who supported people to overcome any inequalities.

People and relatives consistently praised the service and described leaders and staff as approachable, supportive and committed, highlighting the strong, trusting relationships developed with the team.

The service was led by highly inclusive and effective leaders who understood the context in which care was delivered. Leaders at all levels demonstrated the values of the organisation and promoted a culture of integrity, openness and honesty. They possessed the skills, knowledge and experience required to lead safely and effectively.

The registered manager and management team were enthusiastic, motivated and committed to delivering high‑quality, person‑centred care. Staff, people using the service and relatives consistently described the registered manager as approachable, knowledgeable and dedicated to maintaining high standards.

Leaders created a culture where people and colleagues felt valued and respected. The registered manager encouraged creativity and empowered staff to contribute ideas that improved people’s experiences. For example, a staff member with an interest in football collaborated with people and their families to create an Ipswich Town mural, with further themed activities planned. Another care worker with a talent for photography produced high‑quality portraits for personalised memory boxes. These examples demonstrated how leaders recognised and harnessed individual staff strengths to enhance the environment.

Leaders also ensured personalised touches were embedded throughout the service. This included welcoming signs on vacant rooms and black‑tie themed tabards used during mealtimes to promote dignity and add a sense of occasion. These initiatives reflected the registered manager’s understanding of what mattered to people.

Staff reported feeling valued and supported. They received regular 1:1 supervision, benefitted from an open‑door approach from the registered manager, and were encouraged to develop their skills. Recognition initiatives, such as awards, personalised thank‑you cards and shared celebrations, contributed to a positive team culture. Staff told us they felt respected and motivated, which supported high morale and strong staff retention.

The registered manager was a visible and trusted leader who consistently modelled the service’s values. They maintained effective oversight of quality, safety and performance. Succession planning and staff development were prioritised, ensuring the service had a stable and skilled workforce. The provider recognised the registered manager’s strengths and utilised their leadership expertise to support other services within the organisation.

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

The provider had policies and processes in place to support staff to speak up, including team meetings and one-to-one supervision sessions. Staff were made aware of the provider’s whistle blowing policy during their induction and at learning events.

Managers were described as having an ‘open door’ approach and we observed that they were visible and accessible. Staff told us they felt comfortable raising concerns and said leaders listened to their views and acted on feedback when required. This helped create a positive and enabling culture. A member of staff shared, “I feel well supported. If I ever have questions the seniors and managers are approachable. They guide me and help me learn. The team is supportive too; we help each other without hesitation. Managers thank us for our work and recognise when we have gone the extra mile. Colleagues are friendly, and there’s a real team spirit here.”

Feedback was encouraged and used to develop the service. Regular residents and family meetings were held, and annual surveys were sent to relatives, staff, and professionals. In addition, visitors were asked for feedback through the electronic sign-in system, and these were reviewed by the management team to drive improvements in the service and to respond in a timely way.

The provider strongly valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Policies and procedures were in place to uphold equality and diversity, and the provider demonstrated awareness of their duty to respect protected characteristics and prevent discrimination.

Staff felt supported regardless of their background, were treated with respect and could access help and guidance both professionally and personally when needed. All staff received equality and diversity training, and role modelled this in their interactions.

Staff had been recruited from diverse backgrounds including representatives of the local community. Staff told us how the management team were flexible and understanding of their individual needs in relation to their personal circumstances, supporting flexible working arrangements. The provider undertook risk assessments for staff with health considerations that might impact their work. A member of staff shared, “I feel supported at work as I struggle with my mental health, and I have always been told door is open and the deputy manager has offered me help when I am struggling.”

Staff had opportunities to share stories about people’s backgrounds and cultures and told us they had learned simple phrases in different languages and played music from other cultures, explaining why this was important. The registered manager told us, “We have a lot of inclusivity, we try different foods and talk about different countries. We have some stories from people, staff and colleagues to get to know more about each other – we ask where have you been on your honeymoon to holidays to [explore and find out about] different countries and cultures.”

The provider’s district manager told us how the service had created a world map to reflect staff and people’s backgrounds and heritage; to encourage conversations and engagement about their shared lived experiences to create and enhance connections and inclusive relationships.

People’s individuality and diversity was respected and promoted. The service celebrated days including, Diwali, LGBT+, black history month with planned events and linked in with the local community school and nursery children for global intergenerational week.

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.

The registered manager and provider had effective oversight and knowledge of the service. Systems were in place to monitor and manage safety and quality across the service. Regular audits were completed, enabling the registered manager to maintain standards, identify areas for improvement and implement targeted action plans to address any issues to support continual development.

The provider’s senior management team were a visible presence in the service supporting the registered manager and strengthening the oversight and accountability at all levels. They regularly monitored compliance with quality standards, reviewed audit outcomes, to ensure that action plans, lessons learnt etc were implemented effectively and improvements were driven collaboratively.

The provider and registered manager were fully aware of their legal responsibility to be open and honest when things went wrong.

The provider clearly understood and carried out their duty to collaborate and worked in partnership, and services worked seamlessly for people. They always shared information and learning with partners and collaborated for improvement. St Marys had developed effective working relationships with a wide range of professionals, organisations, and community groups, ensuring services worked seamlessly for people. Information was consistently shared in an open, transparent manner, and the provider demonstrated a sustained commitment to shared learning and improvement.

People and those important to them told us they felt valued, involved and listened to, with staff, the management team, and the provider working in partnership to achieve the best outcomes. Information was shared openly to support improvements in care and the service advocated for people to be included in decision making. The management team engaged in discussions with people and their families prior to admission to manage expectations and provide reassurance, recognising how challenging the transition into care can be for both people and their family members.

The provider had built strong collaborative links within the local community. This included partnerships with church groups to support spiritual wellbeing and participation in intergenerational dementia awareness initiatives with local schools. These relationships enhanced social connections, reduced isolation, and contributed to wider community understanding of dementia.

We observed one of the planned visits involving local school children visiting and interacting with people. Everyone was engaged, pupils and people enjoying each other’s company and sharing their experiences. It was a lively and positive atmosphere with lots of laughter. There were plans to collaborate in creating a podcast together to widen the audience and dementia awareness further. The service additionally supported a local wildlife trust through fundraising and donations, they entrusted St Marys to care for resident ducks and ducklings, bringing enjoyment and therapeutic benefit to people.

St Marys served as a professional hub for community-based colleagues, offering a confidential space for clinical work and fostering strong reciprocal relationships. Visiting professionals described the management team as approachable, supportive, and proactive in responding to recommendations, ensuring that care remained coordinated and aligned with professional guidance.

Feedback from professionals was complimentary about the service and the way management and staff worked in partnership with them to meet people’s needs. They confirmed the management team were supportive during visits, receptive to feedback, and proactive in addressing recommended actions. This collaborative approach strengthened relationships with external professionals and ensured people received safe, coordinated care.

The provider had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. As demonstrated when St Marys was selected as a pilot site for delegated clinical tasks, in falls management and wound care through the Care Home Engagement and Support Service. The joint training and implementation significantly improved staff clinical skills and led to a reduction in falls from 50 in December 2024 to 15 in May 2025, alongside improved wound‑healing outcomes and reduced infectionrisks.

The provider and management team demonstrated a commitment to continuous learning and improvement using lessons learned to drive meaningful change across the service. This included regular analysis of incidents to identify root causes to support positive strategies and interventions. For example, if someone had experienced an unwitnessed fall, exploring the circumstances fully to determine if this was an isolated incident or if their needs had changed and if so, what further support such as a referral for specialist help was required. Throughout the inspection there was an emphasis on people’s quality of life and how this could be improved upon to meet their specific needs and preferences.