Ancasta Grove

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 good. At this assessment the rating has remained 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 71 (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.

The registered manager told us they had taken the service through a period of change. This had resulted in staff changes and a change in culture at the service. They explained how they had engaged staff to be part of the shared future of the service, including the introduction of ‘home values’ to sit alongside the provider’s values. Minutes from team meetings showed staff input and we saw the registered manager had ordered a large, framed print of the values to be on display in the reception area for all to see.

Staff told us the culture at the service had improved and that morale was “good.” The registered manager told us they had worked hard to improve morale. They said, “It took a bit of time to turn it round, but now, it feels better.”

Regular staff meetings took place, and we saw minutes of these. Staff said they felt valued working at the service. Several staff told us that following a number of people passing away, that it was recognised that some staff were feeling upset, and that staff were encouraged to discuss their feelings in a supportive environment.

Daily head of department meetings took place, and we saw records of these. Regular staff surveys were carried out. We reviewed the last staff survey, the associated action plan and saw that the next survey was due in a few months.

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.

The management team were visible. People and their relatives knew who the registered manager was. One person’s relative said, “The manager is brilliant. Since she came, there has been a huge improvement.” People told us they knew who the manager was and felt able to approach them if needed.

All staff spoke highly of the management team and said they were “good”, “very kind” and had “strong emotional values.” One staff member said, “[Registered manager] is good. She gets things done and when changes need to be made, she gets them done.” One staff member said, “She's involved. She's passionate about the home, the residents and the staff. I do feel supported and I’m confident I could go to her with any problems.” One health professional said, “The new manager’s active engagement with the practice and the primary care network has contributed to more robust processes and improved communication pathways overall.”

The registered manager showed us many examples of positive changes made to how the service was run, and how they had supported and encouraged the staff to feel more confident and empowered in their roles.

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

There was a whistleblowing policy in place. Staff told us that felt confident to raise concerns and that they would be listened to. One staff member said, “If I was worried about poor care, I would be happy to speak up. I’m confident to speak up and confident that I would be listened to.”

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.

There was a diverse workforce at the service, and the registered manager told us they supported staff to celebrate their cultures and take part in religious festivals. They told us, “We have a couple of staff just about to start [religious fasting period] and one is going to do night shifts where possible. I take into consideration that staff might be fasting, so we will be flexible around breaks for example.”

There was a range of audits carried out across the service including spot checks of staff during the day and overnight. However, in the main, the issues we noted during the inspection had not been identified. For example, medicines audits had not identified the inconsistencies of PRN protocols, PRN effectiveness recording, and personal items stored being stored in the medicines cupboard. Care plan audits had not identified the improvements needed to end of life care plans and plans for people who might experience anxiety or distress. We noted that the provider had already identified where improvements were needed to records relating to mental capacity assessments and best interest decision records. When issues were noted during the audit process, action plans were created with clear recorded information on who was responsible for acting on them. Processes for reporting, investigating, and learning from incidents were effective and records showed learning was shared and embedded with staff. There was management oversight of areas of risk.

Although some of the issues we noted had not been identified during the provider’s audit processes, following the on-site inspection activity, the registered manager updated us with actions taken following our feedback. The provider maintained an improvement plan to track improvements and progress, and we saw where actions had been completed or were ongoing to ensure they were fully embedded.

We saw that during monthly quality assurance meetings, incidents and accidents were reviewed and any trends identified. Action was taken to reduce the risk of recurrence. For example, we reviewed minutes from a meeting where it was documented that falls prevention was the focus for the month. As a result, falls management was discussed during staff meetings, mini training modules were provided for staff, and there was a focus on improved communication during staff handovers, for example. A falls prevention education board in place was on display in staff areas.

The registered manager understood their responsibilities and had systems in place to report appropriately to CQC.

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.

The registered manager had engaged well with the local community. We saw the service had invited local people to join a free event where they could learn more about preventing falls among older people. At the event, physiotherapists were available to provide guidance to the local community on how to prevent falls, reducing balance problems, and information about strength exercises. A group of healthcare professionals told us how the service had been offering space and connecting with primary care colleagues to help deliver local projects. This included the social prescriber community group, which brought people together who might be feeling lonely or isolated. A health professional told us, “It’s a great way for residents to meet others and learn more about the support services available in the area.”

There was carol singing at Christmas where the local community were invited to join in and go from room to room with staff to ensure all people were able to feel included. We saw examples where the service empowered people to contribute to local decision making. For example, the walking group from the service had contributed to a consultation about the pathways being laid in the local park which the walking team regularly used.

The provider 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 contributed to safe, effective practice and research.

The management team showed a strong commitment to learning and continuous improvement. They were open and transparent, and some actions were taken during the inspection to address issues identified. The service responded promptly to feedback and demonstrated a clear willingness to improve. Feedback from people, relatives, staff, and professionals was used to make improvements to care. Leaders promoted an open culture where learning from incidents, safeguarding concerns, complaints, and examples of good practice was shared with staff to reduce the risk of issues happening again.

.