St Anne's Community Services - Alcohol Services

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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

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 inspection we rated this key question good. At this inspection 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. Leaders had the skills, knowledge and experience to perform their roles. Staff knew and understood the provider’s vision and values and how they applied to the work of their team. Staff felt respected, supported and valued. Governance processes operated effectively. Performance and risk were managed well. Teams had access to the information they needed to provide safe and effective care. Staff collected analysed data about outcomes and performance. They used this to identify improvements.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

We scored the service as 3. The evidence showed a good standard. 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.

The service had a clear shared vision, strategy and culture. There was a new 5-year strategy in place which was ran from June 2026 to June 2031. This was based on the values of being proud, person- centred, respectful, open, understanding and dedicated. The provider’s senior leadership team had successfully communicated the provider’s vision and values to the frontline staff in the service. Staff we spoke with understood the provider’s vision and values and how they were applied in the work of their team.

Staff supervision included discussions about organisational values and how staff felt they were displaying these in their day-to-day roles. Staff awards were also based on organisational values. We saw posters around the service in communal areas displaying information about these values.

Staff had the opportunity to contribute to discussions about the upcoming strategy. Managers had sought feedback in the development of this and there was a briefing document about the strategy, which had been shared with staff.

Staff and managers described a positive, person-centred and inclusive culture. Staff at all levels told us there was a consultative approach to work across the service. Many staff told us they felt proud to work for the organisation and told us they enjoyed coming to work.

Managers had attended workshops focussed on culture and embedding positive cultures through leadership.

We scored the service as 3. The evidence showed a good standard. 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 service had competent and inclusive leaders 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 and experience to perform their roles. They had a good understanding of the services they managed and could explain clearly how the teams were working to provide high quality care.

Throughout 2024 and 2025 managers had completed leadership academy training. Managers told us this was practical-based management training which covered a range of leadership and management skills, including finance management, human resources, and health and safety responsibilities.

Staff fed back that there was accountability within the service at all levels. They told us that management were transparent and listened to staff and clients. Staff felt confident in their leaders and able to go to them for support whenever they required this.

Leaders were visible in the service and approachable for clients and staff. Staff spoke extremely positively about managers and senior leaders.

There was positive feedback about client’s experience of the service. The inspection team noted that when they spoke to clients they spoke highly of the staff and the care and support they received.

Leadership development opportunities were available, including opportunities for staff. Some staff described how they had progressed from being a recovery worker into management roles. Staff could complete aspirational courses, and managers described how management-based training was available to all staff and not limited to managers.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

There was a whistleblowing policy in place, which explained the steps for staff to take if they wanted to raise concerns. Staff understood these policies and felt comfortable using them without fear of reprisal. Staff said that they felt listened to by their managers.

There were freedom to speak up guardians within the organisation and posters were on display letting staff know how to contact them.

Managers promoted an open and honest culture and were visible at the service for clients and staff to approach.

Clients were invited to complete treatment perception questionnaires on discharge which enabled them to provide feedback on different aspects of their care.

We scored the service as 3. The evidence showed a good standard. 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.

There were equality and diversity champions within the service.

Staff could apply to work flexibly. Some staff had flexible working agreements to account for personal circumstances such as caring responsibilities and health issues. There was a flexible working policy in place.

Managers put reasonable adjustments in place for staff members to help them carry out their role when necessary.

The provider completed annual equality monitoring of staff within the service to ensure was diverse in its make-up and representative of the client group.

Managers promoted different organisational working groups for people with protected characteristics including black and minority ethnic groups, LGBTQ+ groups and carers groups.

We scored the service as 3. The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Based on evidence drawn from other key questions, governance systems were effective and supported continuous improvement. There were systems and procedures to ensure that the premises were safe and clean, that there were enough staff, that staff were trained and supervised, that clients were assessed and treated well, that flow within the service was managed well, that discharges were planned and that incidents were reported, investigated and learning established.

There was a clear framework of what must be discussed at team level in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed.

Staff had implemented recommendations from reviews of deaths, incidents, complaints and safeguarding alerts at the service level.

Staff understood the arrangements for working with other teams, both within the organisation and external, to meet the needs of the clients. Staff interviews, care records, and observations showed that staff worked with a range of stakeholders to share good practice and learning.

Staff undertook or participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed. These audits included infection prevention and control and medicines management.

Staff had access to the equipment and information technology needed to do their work. The care records system generally worked well. The service used both paper and electronic records, and we found that sometimes staff had not uploaded paper documents onto the electronic system. Managers were aware of this and could evidence action they had taken to address it.

Information governance systems included confidentiality of client records.

We scored the service as 3. The evidence showed a good standard. 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.

Clients and staff could meet with members of the provider’s senior leadership team to give feedback. They visited the service on a regular basis and were actively involved in managing and developing practice.

The service worked effectively with stakeholders to promote joined up care and facilitate engagement and access. This included local mental health services, GP’s, social care, prisons, the local University, and community drug and alcohol services where appropriate.

We spoke to stakeholders, and they told us that they had very good relationships with the service. They confirmed that staff shared information effectively and worked collaboratively to ensure effective care and treatment.

We scored the service as 3. The evidence showed a good standard. 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.

Innovations were taking place in the service. There was a learning and development forum which oversaw workforce capability and development. The forum reviewed training compliance and effectiveness, identified learning needs arising from incidents, safeguarding and quality reviews, and aligned development activity to strategic and quality priorities.

Staff used quality improvement methods and knew how to apply them. There was a 90-day action plan which identified areas for improvement that the service was working towards, with appropriate actions and goals in place. Managers reviewed the progress of the service against this action plan. The service also had a quality and continuous improvement plan. Actions within the plan were developed using incident reviews, and feedback from clients, staff and stakeholders, or in response to national guidance.

Quality leads within the organisation completed regular quality visits at the service and produced reports identifying any concerns or actions for staff.

Other innovations included a project to review outcomes for clients referred to the service whose stated ethnicity was something other than White British, and/or whose first language was not English.

The service was part of a national a network of residential substance use and alcohol treatment centres across the UK, which enabled staff to share learning and good practice.