Archived: St Anne's Community Services - Smithies Moor Lane

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 inadequate. At this assessment the rating has remained inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 36 (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 did not have a shared vision, strategy and culture based on diversity and inclusion, and engagement. Leaders had failed to ensure systems were implemented to ensure people were engaged in a way that was meaningful to them. Concerns found during the previous inspection relating to person-centred care had not been acted on by the provider. Staff reported an inconsistent management team which had contributed to a consistent lack of guidance and support for staff in the service.

The registered manager for the service worked at another home for the provider, a supporting manager had started working at the home, but the provider could not demonstrate that there had been continuous leadership oversight since our last inspection. There had been a number of managerial changes at the service. Even though the area manager was supporting the service during the managerial changes, we received feedback from staff there was a lack of support during the changes and no consistent team meetings. We also received feedback from relatives about the number of managerial changes. One relative commented on the lack of communication around the frequent changes in the managers.

The provider could not demonstrate that they had fostered a culture which would allow people and staff to speak up and their voices heard. There were no surveys completed with people and staff which would allow them to receive feedback and identify areas of improvement. There was a whistleblowing policy in place and staff told us how they would raise concerns if they needed to. Staff were confident to identify poor practice and told us they would raise concerns which would be acted on.

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.Staff had not previously received regular contact with a manager, but this was showing signs of improvement in line with the provider’s policy. Staff told us they were now feeling more supported and that the service was going in a better direction.

The provider did not monitor the quality of care provided in order to drive improvements. The provider had not implemented systems to improve the service for people. People did not have activity plans which meant they did not have the opportunity to engage in activities that met they needs and aspirations or have choice and control over what they did during the day and week. The provider did not hold complete records in respect of care and treatment delivered to people. There were gaps in people’s records which did not assure us people were always receiving care in line with their care plan. The service had transitioned to an electronic recording system. The aim was to have better oversight of the service and identify shortfalls sooner. Although an action plan was in place, it did not identify all the concerns found during our inspection. We were only provided with audits for the period the supporting manager was at the service, which did not identify all the concerns we had found during this assessment.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.They shared information with partners and professionals when needed and we saw evidence of this. We received positive feedback from a professional about the team, they told us the interaction between them and the team was positive, and the staff and manager were fully involved in the care and wellbeing of the people.

The service did not focus on continuous learning, innovation and improvement. Little improvement had been made around the shortfalls found in the previous inspection which meant care was not always person centred. There were no systems in place to gather feedback to improve care for people. The supporting manager was open to make changes where gaps had been identified during our assessment. There was a willingness to improve.