St Martha's

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 did not assess enough quality statements to rate this key question. At this assessment the service has been rated 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 75 (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.

People and were consulted about their care and care plans; relatives’ input was sought where appropriate. Processes were in place to promote equality and diversity for people and the staff team. When we spoke with staff, it was evident the providers values were instilled within them, because they spoke about the people they were supporting, with warmth and respect.

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.

Relatives and professionals told us about the positive and caring attitudes of the management team. We observed the registered manager to be supportive to both people and staff. The registered manager talked passionately about ensuring people living in the home were living their best lives and gave examples of how they do this.

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

People living in the service were asked for their views at meetings and the registered manager had an open-door policy. We saw evidence of the registered manager acting on feedback from people following these meetings. Relatives told us they felt comfortable to speak with the registered manager about any concerns they might have about the service or about individual people’s care. Staff told us they were confident the registered manager would act if they raised any concerns with them.

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 told us they felt supported to give feedback and were treated equally, free from bullying or harassment. People with protected characteristics felt supported. The provider held regular staff meetings and staff told us they were recognised and thanked individually when they had completed a good piece of work.

The provider 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 acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Staff understood their roles and responsibilities. Staff and the management team understood the importance of reporting any changes to people’s wellbeing. They kept good records of the support people had received. Governance processes were effective in monitoring and improving the service. This included monitoring of infection control, care planning, health and safety and fire safety. The provider took action during the inspection to strengthen the monitoring of recruitment records.

There were security measures in place to ensure all paper and electronic information was stored safely and securely. The provider submitted information to partner agencies when required.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Staff and the registered manager shared with us positive examples of collaborative working in partnership with other agencies. A professional involved with the service told us the service worked well with other professionals and worked with them to ensure the best outcomes for people.

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

Leaders spoke passionately about their strong desire to learn and improve the service. The registered manager told us, “We have a weekly education theme. We see access to the community as fundamental to people’s wellbeing. We have an extensive and coproduced activity programme.” The theme of the education week was based upon identified learning needs from clinical data and audits throughout the year.