St Annes Nursing Home

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 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.

This service scored 75 (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 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 provider, manager and staff team had a clear vision for the service which aligned to the service values which were, respect, empathy, accountability, continuous learning and teamwork. The service motto was, ‘Believing and acting on our values translates to really good care where our residents are at the heart of St Annes Nursing Home and everything we do.’ Everybody understood the shared values and direction of the service. The manager and senior team had an ‘open-door’ policy for everyone. There was a strong emphasis on teamwork within the service, and everyone was working towards the same goals, many staff told us they were, ‘family.’ There were clear processes in place to ensure continual improvement. The service actively sought the views of people and their families through meetings, surveys and informal conversations.

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.

People, their relatives and staff were complimentary about the leadership of the service. The manager had the right knowledge, skills, and experience to lead the team, a member of staff told us, “The manager has provided us with stability.” Supported by the provider and the senior team, everyone was positive about the management of the service. Some of the comments included: “The manager is very good”, “The provider is exceptionally polite”, “Our experiences so far have been very positive”, “The manager has not been in post long but is already making their mark. They are very welcoming to relatives and full of energy and enthusiasm”, “The provider, has always been extremely helpful.” The manager kept their knowledge and skills up to date through training, professional validation, peer support, publications and updates to legislation.

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

People, their relatives and staff knew how to raise concerns and speak up. There were various channels available to staff both within the service, for example through the provider, and to external agencies such as the local authority. Staff were confident in the provider and the manager to address any problems they had. They told us the provider and manager was approachable, acted immediately and this was confirmed by people and their relatives. A relative told us, “The manager fully investigated my concern and acted to resolve the matter.”

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.

Staff told us they were happy and felt accepted by their colleagues, the provider and the manager. People and their relatives told us St Anne’s Nursing Home was a happy place to be, they said this was due to the family ownership, staff, the atmosphere, and the management team. Policies and procedures were in place and incorporated all aspects of recruitment and staffing such as equality, diversity, fairness and protected characteristics. The policies underpinned acceptable practices within the service which was reinforced by staff training.

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.

Leadership and oversight was visible, this included checks carried out on behalf of the provider. Governance and oversight were in place and further improvements were planned to strengthen processes. Audits and checks were in place to identify areas for development. The service had made all notifications to CQC as required by law. A notification is the action that a provider is legally bound to take to tell us about any changes to their regulated services or incidents that have taken place in them. All audits and checks produced action plans with timescales for completion. Reviews of action plans were ongoing and had oversight by the provider. The service had several meetings which included daily, weekly and monthly reviews of the whole service. The manager kept a detailed review of the clinical governance which meant people’s clinical needs were examined fully. The providers comprehensive policies underpinned working practices within the service.

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.

Partnerships with external organisations were well established with the service, this included visiting professionals, entertainers and clinicians. Relationships with outside professionals were working well, this had contributed to better care for people. The location of the service was within walking distance of the shops, local parks and recreational areas. People, their relatives and staff told us they continually made use of their local community. The service continued to make and establish relationships and a vital part of the local area. A health and social care professional said, “I feel the partnership between our service and St Anne’s Nursing Home works well, and we are supportive of each other.”

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.

The provider and manager were united in their vision for the service. The manager believed learning, changing and being proactive was the key to excellence in care. They told us, “We need challenge, otherwise we cannot improve.” The provider and manager told us about the ways in which they were continually looking to enhance the service. A relative said, “The manager is a 'hands on' manager and role model for staff. They have shared their vision to residents and relatives alike on how she wants St Anne’s to be in the future and invites people to share their views, positive or negative.” The provider had oversight of the service as they were present and undertook their own checks to ensure safe operation of the service. Overwhelmingly feedback about the management of the service was positive. The provider and manager was confident they had safe systems they could continue to build upon and worked well as a team. They understood the importance of continual improvement within the service. The provider was working on new systems and had recently made partnership links to enhance oversight within the service; they told us the plans were exciting. The manager was confident their systems, processes and their own responsibilities to provide effective oversight of the service. A relative told us, “I feel St Anne's has lots of potential to be a first class home over time and under the manager and providers guidance.”