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 requires improvement. At this assessment the rating has changed to 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 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. New staff received support and training which helped them to demonstrate the provider’s values in their daily work with people. People, relative and professionals were very positive about the care provided, especially the rehabilitative care. Their comments included, “If [Name]had not come here, they would not be with us now”, “It is a very friendly home, I have recommended it.” Professionals comments included, “On behalf of a resident's relative they have commended the exceptional care their relative received at St. Mary's, noting its significant contribution to [Name]’s rehabilitation. While both parties were satisfied with the discharge and return home, the patient expressed significant sadness at leaving the care team and voiced their deep appreciation for them.” Another professional told us "All of the staff from the manager to the cook go above and beyond." Staff comments when asked about working at the service included, “I love coming to work now”, “The best thing about working here is working with the people” and “We have more time to spend with people” and “It feels like family working with people and their relatives.”

The service 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 had made several improvements to the running of the service. People, staff and professionals were complimentary about the registered manager. Their comments included, “The manager is accessible”, “I have consistently observed the manager to be approachable, proactive in resident care, and supportive of the District Nursing Team” and “The manager is a good organiser.”

The service fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had a clear whistle blowing policy. Staff could raise concerns, and written information was available of how to do this. Staff meetings took place, and staff had the opportunity to share comments and give feedback. People were informed of the complaints procedure when they started to use the service and at meetings. A staff member told us, “We can share suggestions, and we are asked for our views.” A relative told us, “I go to the meetings, it is useful to discuss what is coming up.”

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 able to ask for reasonable adjustments to be made to their working patterns for specific needs, for example to incorporate family commitments.

Improvements had been made by the registered manager and area manager to ensure governance was more effective and robust, including the monitoring of the quality of service provision. The service now had clear responsibilities, roles, systems of accountability and better 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. Regular audits and checks were carried out in the main areas of the service, such as, around care records, health and safety and staff practice. Audits showed action was taken where areas of improvement were identified. However, we advised some audits needed to be more robust and more frequent, to ensure timely follow up of actions, with spot checks of the environment to ensure staff following good IPC practice and safe storage of equipment.

Staff at 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. All professionals fed back the service worked in partnership with them. A professional commented, “I have no reservations regarding St. Mary's as a care facility, nor any concerns about its staff.”

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. There was evidence of changes that had been made to the service to make improvements and to address checks and audits outcomes and in response to people and staff feedback. External quality assurance arrangements were in place to monitor the internal governance systems.