St Michaels Nursing Home

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• 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

At our last inspection we rated this question good, this rating remains unchanged. Leaders and staff had a shared vision and strategy for the service, they understood the challenges and the needs of the people using the service. Leaders had taken action to improve the governance structures and outcomes for people. We found leaders ha clear responsibilities and systems of accountability which they used to manage and deliver a good quality service. They acted on information about risk from internal processes and reports from external stakeholders. Leaders were inclusive, compassionate and capable. In a short timeframe they had built positive working relationships with staff within the home, fostering a culture were people feel they can speak up and their voice will be heard. However, there is still more work to done to ensure that the governance processes are embedded and continue to develop the service.

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.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff spoke highly of the management. Comments included, “[The manager is] friendly, available – not just stuck in the office, she is thorough. Yes, she has put her foot down and got things done and the environment is a lot better now and the residents have noticed”; “[Manager’s name] is always compassionate towards residents”; “[Manager’s name] is very compassionate and hard working”.

There had been a change in management since March 2024. This change has had a positive impact for the service. The manager had the skills, knowledge and experience to lead the staff to improve the delivery of care, treatment and improve the culture within the service. The manager has developed positive working relationships with the CQC and external stakeholders based on integrity, openness and honesty. They have an open door policy for staff and although they have had to make some difficult decisions, they have done so to improve the culture and instil the values of the team.

Leaders told us how they act with openness and transparency, even when things go wrong. Leaders told us and the care staff confirmed that staff are encouraged to raise concerns if needed. Staff told us they were confident that their voices will be heard if they raise concerns. Staff gave us examples of how they raised concerns with the manager and they were acted upon. Staff told us they would have the confidence to raise concerns externally if needed. Comments included, “I would go to the person above and inform them and if they didn’t take action, I would call CQC”; “I would express my concerns to the deputy manager and manager and would go to managing director if needed or I would whistle blow and contact local authority or the CQC".

Managers had a whistle blowing policy in place which supported people on when and how to speak up. We saw evidence within the team meetings, safeguarding referrals and outcomes of disciplinary’s that people did speak up, were heard and action was taken to resolve the concerns. Staff were encouraged to provide feedback to managers about training, supervision, managerial support ad their career aspirations in order to meet not only their needs but also improve people’s experience of receiving care. The manager had created a positive culture of openness and honesty where concerns about safety are raised, investigated and that lessons learnt are shared with staff in order to improve practices and outcomes for people who use the service. We reviewed minutes of staff meetings and found that incidents and safeguarding issues were raised with actions to be taken in order to minimise risk. The manager also sent out memos to staff and posted on the staffs mobile platform.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Leaders and staff told us that they were fully aware of their role and responsibilities. Managers told us they could account for the actions, behaviours and performance of staff. The manager gave us examples of how disciplinary actions were taken when they were concerned about staff conduct. Leaders had systems and procedures to continuously audit risks and performance. Managers told us they were aware of areas of improvement, and they had a plan to address the gaps in the quality of the service, for example some shorts in care planning. Managers told us they knew when to submit data or notifications to external organisations, such as CQC. The manager told us she was in the process of registering with CQC. The manager said she felt listened to and supported by the senior leaders within the organisation.

Since being post the manager has defined clear lines of responsibility, systems of accountability and good governance. They are being used to manager and deliver good quality care, treatment and support. However, there is still more work to be done and the work needs to be embedded to bring about sustained improvement. We reviewed the accident and incidents log and found that managers had reviewed the action staff took keep people safe and identified lessons learnt so incidents were not repeated. Incident data was logged and reviewed. The manager completed monthly accident/incident summaries to monitor for themes and trends. Within these summaries the type of accident/incident was identified and if safeguarding referrals needed to be made or people that used the service needed walking aids or sensor matts to reduce their individual risks. Lessons learnt were shared via email and within staff meetings. We reviewed three of these documents and they clearly highlighted risks and actions to be taken in order to reduce risk for people using the service.

People and their relatives told us that staff collaborated with external agencies on their behalf if needed.

Leaders and staff told us they had good links with partner agencies and when issues arouse, they were confident in resolving them in a timely manner.

The manager worked with the integrated care board and the local authority after they had carried out a quality audit at the home. Areas of improvement had been noted. For example, issues with medication not being signed for after administration, staff training, care plans not reflecting individual people’s needs. Throughout the inspection whilst working was on going we did see improvements in all of these areas but there was still more work to do in order to embed the positive changes.

A service improvement plan was in place. The manager had identified within the plan issues that needed to be addressed to improve the care and the safety within the home. This included staffing, premises and equipment, medication management and administration, health and safety, care provided and care documentation. The plan rated the risk, had a plan of action in place with a set timeframe and progress noted. The service had a business continuity plan that had been reviewed and updated in March 2024. The purpose of the plan was to minimise the disruption to people who use the service if there was an incident that stopped and altered the running of the service. The plan clearly highlighted the actions staff were required to take and who to contact, including local authority, senior management and amenity providers (gas, electric).

Leaders told us they focused on learning, innovation and improvement of care for people. They told us they had systems and process in place to review incidents, accidents and near missed and learn lessons from them. They said they welcomed feedback to guide them to make improvements. Leaders told us they provided people and their relatives with platforms to share feedback to aid improvement. Staff told us the trusted the manager. Since there has been a change in the leadership within the service it has been noted by staff that there have been improvements within the service. Staff reported that they were now supported with the changeover to electronic care records. We observed physical changes in the environment for people using the service too. The refurbished quiet room is now a pub, the small conservatory is now a snack shop with a sweet cart and seating giving the area a feeling of a café and a bus stop with a bench for people to sit on.

The manager had developed systems to learn from incidents/accidents and feedback from stakeholders to make improvements within the service. We reviewed a quality audit completed by the local authority and found that the manager had addressed all the areas of concern. Although there was still more work to be completed the manager had made significant progress. In addition to this the manager kept staff informed of the actions that needed to be taken to improve the experience for people using the service.