St Mary's Nursing 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 inspection we rated this key question requires improvement. At this inspection the rating has remained requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider was previously in breach of the legal regulation in relation to a lack of good governance, oversight and monitoring of the service and ineffective leadership by the provider. At this assessment we saw this had improved significantly. However, there remained a need to embed the improvements that had been made into practice and for continued improvement in some areas of care planning and provision.

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 promoted a positive culture of continuous learning and improvement. The provider had a range of policies and procedures which reflected legislation and best practice guidance. Staff were familiar with these and understood the organisation’s values.

Work was being undertaken to improve the effectiveness of governance and management systems. Information about risks, performance and outcomes was used to improve care and improvements had been made with the personalisation of people’s care. However, there was need to make sure these improvements were embedded into practice and were consistent for all people using the service.

The provider recognised the need to make improvements to the service. They were keen to hear feedback and used it constructively to identify actions for improvement.

The care consultant was knowledgeable about priorities and challenges in the service and told us they had access to appropriate support and development in their role. There was an experienced clinical lead who provided clinical oversight and guidance for nursing and care staff. The provider had worked with the clinical lead to help promote their role in quality assurance and leadership .

The provider had improved quality monitoring and there was a more effective approach to clinical leadership and oversight in place. There was improved management oversight of audits. People’s wishes and preferences for their care had been considered and alternative, less restrictive solutions for managing risk had been explored and implemented. Care and support was more personalised to the needs of the individual.

The provider were positive about supporting people to speak up and have their voice heard. Staff recognised this.

The appropriate policies and procedures were in place which gave support to people to ensure their voice was heard.

People and their relatives told us the provider sought their views. One person said they did not remember being asked to complete a general survey but had they had recently been involved in a survey about the quality of the food, saying, “I said it was gorgeous and there is a good variety.”

The provider had invested time in having staff meetings and discussions and staff felt more included and informed. Additional training and support had been organised for staff.

Some care staff were recruited from overseas. There was an equality and diversity policy in place and the provider aimed to create a working environment in which all individuals were able to make best use of their skills, free from discrimination or harassment, and in which all decisions were based on merit.

The provider had improved quality monitoring and there was a more effective approach to clinical leadership and oversight in place. There was improved management oversight of audits. People’s wishes and preferences for their care had been considered and alternative, less restrictive solutions for managing risk had been explored and implemented. Care and support was more personalised to the needs of the individual. However, there remained a need to embed these improvements into practice.

The provider had made improvements in assessment and planning of people’s care overall. However, there remained shortfalls identified by CQC in relation to some people’s care plans which had not been picked up by the provider’s audits.

The provider had made good progress with ensuring people’s care was personalised to the needs of each individual.

We fed back to the care consultant that not everyone was clear about who was managing the home. One person said, I don’t know, who is in charge.” One family member said, ”I don’t think there is a manager, there is a management company. I speak to the nurse, I think she is OK. Whenever I have gone to her, I found her to be approachable.”

There were people who wanted more opportunity to get out and about. People and staff told us that since the activities lead had left, and because of the lack of a staff time, there was a need to redevelop links with the local community, including with local religious organisations.

The provider recognised the value of working with partners and the local community. They welcomed partners into the care environment and valued their constructive feedback and support.

There was improved understanding of local NHS pathways, systems and processes in the clinical staff team and the provider demonstrated their willingness to work with partners effectively to meet people’s needs. They continued to welcome feedback on the care people received and this helped drive improvement.

We asked people if the staff worked together well. One relative said, “The girls who do lunches, the cleaners and carers have too much to do. They are good in the way they work together, to help each other.”

The provider recognised the value of a culture of continuous learning and improvement and there was improved support for, and oversight of, the clinical lead.

Progress had been made in relation to previous concerns identified and raised. There was improved quality assurance and oversight by the provider. Clinical leadership and systems and processes were more effective. However, continued improvement and learning was required and the improvements already achieved needed to be embedded into practice.