St Mary's Care 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 inadequate. 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 continuing breach of legal regulation in relation to governance.

This service scored 57 (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. 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.

Leaders promoted an open and inclusive culture where staff felt valued, informed and involved. Staff consistently described the home as “well run”, “organised” and a “happy environment”, and highlighted strong teamwork and a supportive, visible management team.

People benefited from a culture of empowerment and positive engagement. Residents were described as forming strong friendships, taking pride in their home, and contributing to decision‑making about activities and daily routines. External professionals also described a positive culture, noting that staff built strong relationships, understood people's needs well and created a positive environment.

The provider did not always demonstrate consistently capable and inclusive leadership. The provider was working towards aligning the service with the principles of ‘Right support, right care, right culture’ guidance, but further and sustained improvement was needed with this. For example, the premises and how it was used was still largely communal in nature and work to change this to meet the principles of ‘Right support, right care, right culture’ guidance was at an early stage.

While staff reported that the registered manager was supportive, approachable and visible there were leadership gaps in areas including oversight of risk and capacity‑related decisions.

While leaders were committed to improvement and staff expressed high confidence in them, these governance issues and gaps in specialist training meant leadership was not yet consistently effective or fully aligned with best practice in specialist learning disability services.

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

Staff consistently reported that they felt confident raising concerns and trusted that management would act promptly. Feedback from multiple staff demonstrated this culture. One member of staff said, “If I saw something concerning, I would act straight away. Staff described an environment where safeguarding procedures were well understood, senior staff were accessible, and communication was clear. Regular supervisions, handovers and team meetings gave structured opportunities for staff to share concerns or insights. The registered manager also emphasised promoting an open culture where staff were confident to escalate concerns without hesitation.

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

Staff described a generally positive and respectful culture, with management valuing staff feedback and supporting development. We also saw examples of culturally sensitive support for people, such as adapting food choices or supporting communication needs. The culture was warm and inclusive in practice, and the provider had established robust systems, monitoring and training needed to demonstrate sustained workforce equality and inclusion.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Governance systems were not always effective in identifying and addressing risks or ensuring compliance with legislation. Leaders carried out audits and checks, but these had not identified several issues found during the assessment, including unsafe window restrictors, environmental hazards, gaps in MCA practice, and missing or unclear DoLS information.

Although some improvements had been made since previous inspections, such as better care plans, enhanced activities and community access, governance oversight remained inconsistent. Notifications of police incidents were also delayed until inspectors highlighted the omission.

Staff described the service as well organised day‑to‑day, and external professionals noted improvements in leadership stability and culture. However, further and sustained improvements were needed in governance systems to ensure quality, safety and risk were consistently monitored, analysed and acted upon.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people.

The provider worked with a range of external professionals and agencies, but partnership working was not yet consistently effective or fully coordinated. Some professionals gave very positive feedback, describing strong communication, proactive support and staff engagement.

However, there were also gaps in effective partnership working. For example, there were sometimes delays in staff obtaining or following specialist advice related to MCA and consent. Where intensive support teams or social workers were involved, not all information was consistently or accurately documented.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

The provider needed to further promote and sustain an effective culture of learning and continuous improvement. Staff and leaders demonstrated willingness to reflect, adapt and embed changes. The service developed a wide range of new educational and skill‑building programmes for residents, including healthy‑eating workshops, community safety sessions, budgeting education and enabling‑kitchen activities. These initiatives were meaningful and person‑centred, with residents reporting positive experiences.

However, further work was needed embed the principles of ‘Right support, right care, right culture’ guidance at the service. This included improvements in relation to the use and layout of the premises and to effectively obtaining and recording consent.