Ann House

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 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.

Staff and managers worked together to promote the vision and values of the service. The registered manager told us, “We aim to instil in staff to promote as much independence and reduce restrictions as possible.”

Staff and leaders demonstrated a positive, compassionate, listening culture that promoted trust and understanding between them and people using the service. One staff member told us, “I love working here, and seeing people learn new skills is amazing.”

The culture was focused on facilitating mutual trust between leaders and staff as well as learning and improvement.

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.

The management team at Ann House was made up of leaders who had the skills, knowledge and experience and credibility to lead effectively. While the registered manager was not always present at Ann House due to managing other services in the organisation, they were accessible when required. One health and social care professional told us, “The service is run really well. [Registered manager] is very knowledgeable about the people living there.”

There had been structural changes within the organisation which had led to some positive outcomes. The registered manager told us, “We now work more closely with senior managers and governance is much more service focussed.”

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

Staff felt able to speak up about any concerns they had with the management team or outside the organisation. One staff member told us, “I’d be the first to speak up if I had to. And I often have done.” Another staff member told us, “I can report any concerns to CQC, if needed.”

The service had a whistleblowing policy which staff understood.

The service 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 mostly felt equal members of the team and valued as individuals. One staff member told us, “We are all treated equally by management. Work is distributed fairly.”

Staff we spoke with felt well treated by managers who proactively promoted inclusion and diversity. One staff member told us, “There have been instances of discrimination against staff which managers dealt with by working with people about their views and displaying zero tolerance posters in the home.”

The service had governance systems and structures in place; and held regular governance meetings to review the quality of care provided. However, governance processes had not identified some of the issues we found at this inspection.

Safeguarding audits had not identified issues found with the service’s safeguarding policy or availability of safeguarding guidance on the premises.

Medicines audits had not identified issues found with a lack of guidance available in people’s care plans about how they wished to be supported with their medications; and recording issues with people’s creams and ‘as required’ medicines.

IPC audits had not identified issues found with food labelling and omissions in drinks temperature records.

However, processes in place to manage the safety of the environment were effective.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. We saw evidence the service had worked closely with health and social care partners to improve people’s quality of life.

They shared information and learning within the organisation and with partners and collaborated for improvement.

However, we received some feedback suggesting the service could be more present at community events.

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.

The leadership team worked well together with a focus on delivering good care and improving systems.

Staff spoke of their confidence in the management team and their ability to continually improve the service. One staff member told us, “Since our restructure, we have a better connection with the region. We are influential and educate our other services with the positive work we do here.”

Staff were supported to prioritise time to develop their skills around improvement and innovation. One member of the management team told us, “The organisation has supported me to complete management courses, and I know others who have started out as support workers and been promoted through the ranks.”

The management team had put in place an action plan straight away to ensure feedback from the inspection leads to improved practice.