St Cecilia

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 good. At this inspection the rating has remained good.This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 79 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service 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.

The provider and registered manager had a clear vision for the service. Everyone understood the shared values and direction. The registered manager had an ‘open-door’ policy in place; people, their relatives and staff told us they were always accessible. There was a strong emphasis on teamwork within the service, and everyone was working towards the same goals to achieve the best outcomes for people. Clear processes were in place to ensure continuous improvement, these were being strengthened during and after the inspection. The service actively sought the views of people and their families through individual conversations, surveys and telephone calls.

The service had exceptionally 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 always did so with integrity, openness and honesty.

Without exception, everyone could not speak highly enough of the registered manager and their dedication to people, relatives and staff. A relative said, “The registered manager is so in tune with their staff, and their approach is really holistic.” Another relative said, “The registered manager, they are family, like a brother to me, very understanding.”

The registered manager had extensive experience and skills that promoted excellence in their staff team. They worked with staff, giving them trust and autonomy, they were selfless and highly motivated to provide the best care possible for the people living at St Cecilia.

External partners were unanimous in their views about how the registered manager was exceptional in their leadership of the service and impact on others. The registered manager worked tirelessly to build links with external agencies and professionals for the good of the people living at St Cecilia. A health and social care professional told us, “I believe the registered manager goes above and beyond to make adaptions to facilitate person centred care, from talking with the registered manager it is clear that they care for the individuals who live within the care home.”

Staff told us they had the utmost appreciation of the registered manager and their leadership was highly visible; they were considered an integral part of the team. A member of staff said, “The registered manager has an excellent listening ear, you can go to them with anything, and they will act.”

Everyone told us they were confident in the management of the service and that it was exceptionally well led.

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

Staff knew how to raise concerns and speak up. There were several ways available to staff both within the service and externally, for example to the provider, and local authority. Staff were confident in the registered manager to address any concerns they had. They told us the registered manager was approachable, and this was confirmed by people and their relatives.

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

Staff told us they were happy and felt accepted by their colleagues and the registered manager. People and their relatives told us St Cecilia was home for them. Policies and procedures were in place and incorporated all aspects of recruitment and staffing such as, equality, diversity, fairness and protected characteristics. The policies underpinned acceptable practices within the service which was reinforced by staff training.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Leadership and oversight were visible, this included monthly checks carried out on behalf of the provider. Audits and checks were in place to identify areas for development; the provider was working to develop the process further. The registered manager had made all notifications to CQC as required by law. A notification is the action that a provider is legally bound to take to tell us about any changes to their regulated services or incidents that have taken place in them. All audits and checks produced an action plan if necessary and these had clear timescales for completion.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Partnerships with external organisations were established with the service. The service worked effectively with many external professionals and services. Staff told us they worked well with others to enable them to enhance or meet the needs of people.

Professionals who worked with the service were extremely complimentary about their working relationship with St Cecilia. The registered manager told us they communicated well and had several links with external partners and agencies. A health and social care professional said, “I believe that there is a positive and high standard working relationship between St Cecilia and myself.” Another professional told us, “There is a good working relationship between St Cecilia’s and our service.”

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

The registered manager and provider told us about the ways in which they were continually looking to enhance the service. The provider had oversight of the service and undertook their own internal checks to ensure safe operation of the service. Overwhelmingly feedback about the management of the service was positive. The registered manager was confident they had safe systems and worked well as a team. They understood the importance of continual improvement within the service and together with the provider had plans to enhance and develop these systems further.