St Mary's Court

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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

We identified 1 breach of the legal regulations. The provider’s governance processes were not robust in identifying and addressing concerns in the quality and safety of people’s care. The provider had not always engaged with people and those important to them effectively to discuss changes in the service and address concerns. Staff did not always feel listed to. We received mixed feedback about the capability and openness of the management team. The provider had not used feedback and learning to drive improvements in the service. At the time of the assessment, changes in the management team were leading to improvements in oversight and communication; however, these changes were not yet embedded.

This service scored 50 (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 undergone a number of changes within the management team since the new provider had taken over and we received mixed feedback about how well the provider had communicated and managed these changes. Staff told us the culture and stability of the service had very recently improved with the arrival of the new manager; however, improvements were still being embedded at the time of the assessment and not all staff felt the culture was positive. Comments included, "The managers are approachable, but some are not attentive to concerns and will tend to ignore some of our concerns and I feel not supported or listened to" and, "Ever since the new manager assumed office, the home has been better. We always share our opinions with them and they listen. This is all in a bid to make the overall working experience a better one." The provider told us they were aware of the team's concerns and were continuing to meet regularly with staff to gather feedback, address concerns and discuss changes within the service.

The provider did not have robust processes in place to engage with people, relatives and staff and communicate changes. Feedback suggested there had not been open and transparent communication about the change of provider or the impact of this on the service. The management team were addressing these concerns at the time of the assessment and were implementing more robust systems to gather feedback and improve communication. This included increased manager visibility and availability and more regular meetings and feedback requests. However, these processes were not yet embedded.

We received mixed feedback about the effectiveness and capability of leaders in managing the concerns associated with the change in provider and new management of the service. There was no registered manager in post at the time of the assessment. The provider told us they were focused on ensuring the right management team were in place going forward and had transferred an interim manager into post from their quality improvement team to provide day to day oversight and to support any new registered manager once in post. We received positive feedback about the new interim manager and the improvements made since their arrival. This had led to an increase in staff confidence in leadership and improved morale.

Leaders had not always demonstrated the appropriate level of openness and understanding to manage the recent changes within the service effectively. The provider had acknowledged where lessons had been learnt and apologised where appropriate. At the time of the assessment, improved processes were being implemented to ensure increased visibility of the management team and more clearly defined roles. This made it easier for people, relatives, and staff to find the right members of the management team to address any issues or voice concerns.

Staff told us they had not always felt listened to; however, they confirmed this was now improving. Staff we spoke with were able to identify members of the management team who they felt comfortable approaching and would speak to if they had any concerns. The management team told us they were aware supervisions were not taking place regularly and this impacted on staff's opportunity to share concerns confidentially on a one to one basis. This was in the process of being addressed at the time of the assessment.

The provider had a whistleblowing policy and process in place for staff to follow. Information was available to staff about how and where to raise concerns anonymously if required. The provider was in the process of scheduling one to one supervisions with all staff to provide the opportunity to share concerns and have their voices heard. This was not yet fully implemented at the time of the assessment.

Staff told us they had access to relevant training and the provider offered learning and support appropriate to their job role and individual needs. The provider told us they were continuing to develop the culture of the service to ensure it was welcoming and inclusive for staff.

The provider had policies in place to support fair recruitment, induction and training for all staff. The provider confirmed they had organisational processes to follow to identify and address any concerns with staff's working environment or access to development opportunities.

The provider told they were implementing improvements in their governance processes. However, we found the current governance processes did not effectively manage risk or drive improvement, with the same issues being raised repeatedly. For example, the poor completion of people's daily care notes was discussed every day during the staff meeting; however, issues with poor completion remained. Staff told us there was now more regular communication from the management team and clearer systems for recording information were being introduced. However, these systems were not yet embedded.

The provider's governance processes were not robust. We found a number of concerns with their oversight of care planning, risk and incident management, health monitoring charts, DoLS applications, staff supervision, the quality of food and drink and engagement with people, relatives, and staff. These concerns had not been identified and addressed by the provider's internal governance processes. At the time of the assessment, the provider was making improvements to their processes. However, feedback suggested many of the positive changes had only taken place in recent weeks under the new interim manager. This meant the provider had not previously addressed these concerns promptly or effectively. We were not assured the provider's governance processes were embedded or robust and this meant there was a risk improvements would not be sustained in the future.

People were supported by a range of different health professionals who worked alongside staff to support their needs and improve their outcomes. The provider welcomed community groups into the service to ensure people felt involved in their local community.

The provider told us they were engaging with the local authority and other health and social care professionals to address concerns and demonstrate how improvements were being made. Staff were able to demonstrate how they had involved other professionals in people's care including health referrals, care reviews and multi-disciplinary team meetings with other health professionals.

We received mixed feedback from health and social care professionals about how well the provider communicated. Some concerns were raised about how promptly information was shared and how well recommendations were followed. However, feedback suggested this was now starting to improve as there was more stability within the management and staffing team.

The provider had processes in place to seek support from other health professionals and work in partnership to improve people's care. However, these processes had not always worked effectively to ensure prompt and accurate information was shared. The provider told us they were now engaging with stakeholders regularly and they had shared learning across the organisation to drive improvement.

The provider had not always used learning to drive improvement in the service. People, relatives, and staff told us they had not been notified of, or involved in, changes in the service. Where concerns had been raised, the feedback suggested these had not been addressed effectively leading to concerns being raised repeatedly. This meant the provider was not able to demonstrate continuous learning to improve people's experience of care. During the assessment, the management team told us they were aware improvements could have been made when taking over from the previous provider and lessons had now been learnt. The provider had apologised where appropriate and were actively seeking more engagement and feedback from people, relatives, and staff in order to learn and develop the service.

The provider's processes were not always effective in driving continuous improvements and learning. For example, where concerns were raised, actions had not always been taken promptly to ensure those raising concerns were fully involved in discussing what improvements had been made and evaluating whether these improvements were working effectively. The provider was in the process of introducing more robust processes and had implemented an action plan to address the concerns identified by the local authority's quality audit. They had also created a wider service development plan prioritising areas of improvement to address first and planning longer term management arrangements and support for embedding systems.