St Peter's House

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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 assessed a total of 6 quality statements from this key question. We have combined the scores for these areas with scores based on the rating from the last inspection, which was requires improvement. Our rating for this key question remains requires improvement. At our last inspection we identified a breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Not enough improvement had been made at the time of this assessment. We found the provider’s systems had failed to effectively assess, monitor and mitigate the risks relating to the health, safety and welfare of people. This was a continued breach of Regulation 17.

This service scored 61 (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.

Since the last inspection there had been a new registered manager employed. People, their relatives and staff were mostly positive about the approach of the registered manager. Staff told us the manager was approachable and open to their sharing ideas to improve the service. Comments included, “The manager is approachable, and the atmosphere is now not so intense.” And “Things are much better since the new manager came here. You can approach [them] with ideas, and [they] do listen.”

The inspection identified a culture amongst senior care staff in need of improvement. Senior care staff were not fully understanding of their roles and responsibilities. This was evident from recent incidents whereby people had not received their medicines as prescribed and poor communication in handling concerns and complaints. The provider was keen to address this and take the right action. The provider’s representatives from within their oversight team visited the service regularly as part of their quality assurance measures and to maintain a view of the quality of care delivered.

Staff told us the new manager had created a more open, inclusive culture where they felt more at ease to speak up and contribute ideas. However, staff also told us not all concerns brought to the attention of the manager had been evidenced with records maintained of actions taken in response. For example, concerns raised by relatives.

The service had systems in place to allow people to speak up. We saw evidence of feedback opportunities such as an electronic system in the reception area inviting visitors to leave comments as well as ‘you said, we did’ surveys. There was further work needed to ensure robust recording of concerns and complaints, with oversight and review with a clear audit trail of responses and outcomes. This was evident from discussions with relatives and people who used the service. People gave examples of concerns and complaints they had raised which had not been recorded within the provider’s governance systems and so there was no evidence of oversight, actions taken and learning.

Staff working within the service were from diverse backgrounds and told us they were included and accepted. Staff felt supported and described being treated fairly and equally regardless of any protected characteristics.

There were policies and procedures in place to ensure the provider met their legal obligations to staff and work towards a fair and inclusive culture. Staff were supported to complete equality and diversity training.

Leaders told us the service was in the process of implementing improved quality and compliance systems to improve oversight and governance. We found quality assurance systems in place had not always been effective in identifying the shortfalls we found at this assessment. For example, leaders were not aware of all complaints received.

The provider had a focus on continuous learning and improvement for the service. At the last inspection, we identified a breach of regulation 17 due to ineffective governance processes. This assessment identified improvement with further work needed. For example, in the management of concerns and complaints, communication within the senior team and robust monitoring of medicines and care plans.

Overall, people and their relatives felt there had been improvements in the leadership at St Peter’s House, but effective communication remained a concern at times. One relative told us, “The new management is less defensive than the previous and at the meetings they don’t just give a stock answer.” Another relative commented, “If I have any concerns I would go straight to the manager, but I think the general communication is in need of improvement. Team leaders don't always pass on messages or get back to you if you have a query.”

Staff told us the management changes at the service had been a positive influence on improving the service people received. One staff member told us, “Things are a lot better now. The manager is more approachable than the last one, you don't feel afraid to go to them with things.” Another staff member said, “We are in a better place, it is a much happier home under the new manager.”

No concerns or comments were raised by partners when we gathered feedback as part of our inspection.

The provider demonstrated a focus on continuous learning and improvement. At the last inspection we identified a breach of regulation 17 due to ineffective governance processes. This inspection identified that whilst there was a system of oversight in place, it did not identify the areas requiring improvement we found. For example, people's feedback was not always acted on, medicines management shortfalls not always identified and where monitoring of care plans and risk assessments lacked detail.

Staff and leaders told us that they were aware of how to report and investigate events and incidents. However, we identified incidents where senior staff did not escalate concerns and complaints appropriately. This meant investigations had not taken place until pointed out by inspectors. The registered manager provided examples of their responses to suggestions made by people to improve the service they received. For example, via their ‘You said, we did’ scheme. The service provided a dementia cafe, where people who used the service, their relatives, friends, and people from the community could attend. This provided people with the opportunity to share experiences and access talks from specialists. People had access to a wide range of activities with designated staff employed to facilitate this provision. The registered manager gave examples of how people had been supported to access activities of their choosing through a ‘My wish scheme.’ Photos displayed showed people enjoying trips out as part of this scheme. This included access to air shows, picnics in a park and other activities of their choosing.

The provider understood their obligations for submitting notifications to CQC, as required by law. There were systems in place to seek people’s views as to the quality of service received. Further improvement was needed to ensure robust records were maintained with trends and analysis in responding to concerns and complaints. We discussed the areas for improvement we found during the assessment with the provider. They were open, transparent, and responded immediately to ensure actions were completed both during our assessment and shortly afterwards. We found the provider was very responsive and wanted to learn from incidents and was keen to ensure improvements were embedded.