St Martins Residential 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 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.

The service was in breach of legal regulation in relation to good governance.
 

This service scored 62 (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 for the service. The registered manager advocated a positive and compassionate culture that promoted understanding between staff and people using the service. Staff had undergone additional training to give them the skills they need to care for people living with dementia. Staff we spoke to were passionate about caring for people, and there was a common ethos amongst staff that they wanted the service to feel like home.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience, and credibility to lead effectively. They did so with integrity, openness, and honesty.

The registered manager told us they felt supported by the nominated individual and the trustees. Following our last assessment, the service had recruited a trustee with adult social care experience, however, this person had since stepped away from the position. The registered manager explained that they had found this support beneficial and that the service was actively seeking someone to replace them. In the meantime, the current trustees had completed training to better support the registered manager and help improve the service.

Staff told us the registered manager was always visible and available. Comments from staff included, “[Registered managers name] is very supportive, she always listens to us” and “She is a very good manager. The best manager I've ever had. She is truly caring, she understands and helps us.” One person using the service told us, “The manager is approachable and efficient, I think its run well.”
 

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The registered manager encouraged staff to raise concerns and promoted the value of doing so. The registered manager explained that they had an open-door policy, and they encouraged staff to approach them with any concerns they might have. Staff were confident that they would be listened to if they voiced concerns. One member of staff told us, “If I have a concern, I go to [registered managers name] straight away, or even if I have a suggestion, she always listens to me and the other staff. She tries to respond to all of us. Some of the staff are shy, but [registered managers name] encourages them to talk to her or the seniors.” Staff were also aware of external agencies they could raise concerns with such as the local authority and CQC.

People and their relatives were encouraged to share their views through regular meetings and surveys. One relative told us they had previously raised concerns and the staff had been very responsive to this.
 

The provider valued diversity in their workforce and an equality and diversity policy was in place. The service worked towards an inclusive and fair culture by improving equality, equity and diversity for people who worked for them. Staff were employed from a range of cultural backgrounds and heritages. Staff we spoke to said they were treated fairly and spoke of how they supported each other. One member of staff told us,” I feel supported by everyone, all the staff are approachable, we work as a team. We get given good feedback when things go well.”

The providers governance systems were not always effective in identifying the shortfalls we found during this assessment.

Governance arrangements remained inconsistent and there was insufficient evidence of effective quality assurance and monitoring of the service. Furthermore, additional work was required to ensure the quality of care records and consistent recording in people’s daily notes, care records and monitoring charts. For example; gaps in planned care were not detected and there were no effective processes to recognise these shortfalls.

As a result, the service had missed opportunities to learn from these issues and drive improvement. Although fewer concerns were identified at this assessment, there were concerns that had not been detected by the services existing systems. Additionally, records such as care plans and risk assessments were not always robust enough to manage risk effectively. Information provided by staff did not always align with what was documented in care plans and these discrepancies were not identified by the service’s quality assurance tools. This meant people were at risk of not receiving the care and support they needed safely.

During our assessment, we observed some improvements. The service had introduced systems and processes to monitor records in areas where issues were previously identified. For example; improvements were noted in assessing people’s mental capacity and an audit was implemented to observe mealtimes. However, governance and audit arrangements for the oversight of medicines, as identified earlier in this assessment, were not always effective or in place where needed.
 

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. The service worked in collaboration with other services such as the continence service, GP and district nurses to ensure good, joined up care for people. External health professionals that we spoke to said that their experiences with the service were positive. People and their relative’s felt people were supported to access services they required in a timely manner and said the service kept them up to date. One person told us, “I’ve been here for 7 months, it’s very nice here, it is homely and if you are not well, they are straight on the phone and get a doctor to come out.”

The provider had not always focused on continuous learning, innovation, and improvement. At this assessment we found the provider remained in breach of the regulations relating to safe care and treatment and good governance. Although new quality assurance tools had been introduced, they were not fully effective in identifying shortfalls and did not consistently drive ongoing improvement. Further work was still required to ensure people’s care records were accurate, complete, and reflective of their current needs. In particular, the quality assurance processes did not consistently identify areas for improvement in care records relating to safe care and treatment. However, we found no evidence that people had been harmed. The management was invested in making improvements, but learning was being missed due to not identifying shortfalls. The registered manager and nominated individual were responsive and open throughout the assessment and recognised that improvements were needed.