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 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 governance at the service.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Provider systems and processes designed to monitor the quality of the care provided was not always effective. The provider and registered manager did not always understand the challenges and the needs of the people being supported.

The provider and registered manager did not recognise deficits in their governance and monitoring systems. We found the learning and improvement culture was not as robust or embedded within the service to make sure all risks were managed and minimised.

Staff meeting minutes referenced the providers shared vision, strategy and values and these were shared with staff. However, when we spoke with staff, they were unable to clearly demonstrate an understanding of the provider’s ethos and values or confirm where this information was located.

The provider and registered manager did not always have the skills, knowledge and experience to lead effectively.

Whilst there was an established registered manager at the service to support and guide staff, the provider’s and registered manager’s governance arrangements had failed to identify the issues we found during our assessment. This lack of oversight potentially placed people at risk of unsuitable or unsafe care.

The registered manager told us they felt supported by the organisation.Staffs’ comments about the manager were positive and included, “[Name of registered manager] is great, they are so supportive” and “[Name of registered manager] is approachable, you can talk to them about anything. I find them helpful and understanding.”

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

Arrangements were in place for gathering peoples’, relatives’ and staffs’ views relating to the quality of the service provided at St Martins Residential Care Home.

There were systems in place to enable staff and others to speak up when something was wrong. Staff understood this and told us they felt confident doing so. Staff we spoke with knew they could raise concerns with the provider, registered manager and other external agencies.

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

There was a diverse workforce at the service, with staff employed from a wide range of backgrounds, cultures, and experiences.The provider and registered manager were able to provide examples of how they developed and supported a compassionate, collaborative, and inclusive culture at St Martins Residential Care Home for all staff employed at the service. Staff spoken with confirmed there were opportunities to discuss their development through formal supervision and appraisal. Staff felt there was good teamwork at the service.

The provider did not always have clear responsibilities, roles and systems of accountability or good governance arrangements.

The quality assurance and governance arrangements in place were not effective in identifying shortfalls found at the service as part of this assessment. As stated within this assessment report, this referred to non-compliance with the Mental Capacity Act. Risks to people’s safety were not routinely identified and recorded. Care plans were not routinely accurate or recorded all of a person’s care and support needs. Not all care provided by staff for people using the service was person-centred. Whilst the registered manager implied, they were aware of the above, they had not taken enough action to address this and to mitigate the potential risks of people receiving inappropriate care.

The Service Improvement Plan submitted to the Care Quality Commission on 8 March 2025, made no reference to the shortfalls identified as part of this assessment.

Senior staff were not available to provide support and guidance to staff to enable them to effectively carry out their roles and responsibilities. Staff did not recognise their responsibility and accountability to identify and question poor practice with colleagues when this was evident. For example, during people’s dining experience.

Relatives were positive about the overall management of the service. Relatives told us, “The manager is excellent, and we have a good relationship” and “It [St Martins Residential Care Home] is well run.” All relatives spoken with told us they would recommend the service to others.

Services that provide health and social care to people are required to inform the Care Quality Commission, (CQC), of important events that happen in the service. This enables us to check that appropriate action had been taken. The provider had submitted statutory notifications to the Care Quality Commission as required.

The service collaborated and worked in partnership with other services so as to promote effective joint working to meet people’s needs.Information demonstrated the service worked with others, for example, the Local Authority, healthcare professionals and services, such as the local Dementia Intensive Support Team to support care provision.

The provider did not always focus on continuous learning and improvement across the organisation and local system. They did not always actively contribute to safe and effective practice.

The provider’s audits had not been effective at identifying where improvements were required. Concerns we identified during our assessment had not been picked up by the provider’s internal audits or through their own visits made by trustees of St Martins Residential Care Home. Trustees are responsible for the overall governance of the service, ensuring the service operates effectively for people’s benefit. They play a crucial role in ensuring peoples’ needs are met and acting if standards fall below expectation. Whilst it was positive that frequent visits had been undertaken to the service by a member of the board of trustees, these visits had failed to recognise the shortfalls identified as part of this assessment.