Anna S Proctor House Care 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 assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

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

This service scored 61 (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. Staff spoke positively about the provider’s culture and values and said they were happy working at the service. One member of staff described the provider and registered manager as, “Wonderful, supportive and always accommodating.”

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. The registered manager was a visible presence at the service and was well known to people and relatives. One relative told us, “[Registered manager] has always told me she's at the end of the phone any time, she is there even just to talk.” A member of staff we spoke with said, “I believe the service is well ran and managed.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Relatives told us they and people living at the service knew who to raise issues with, and records showed that action was taken when people had spoken up.

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 gave us consistently positive feedback on how they were included in the running of the service. One member of staff said, “The service is ran very professionally, I have no complaints.”

The provider did not have consistently effective systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes in relation to medicines management. This had been identified as an issue at our two previous assessments of the service, and remedial action had not been taken by the time of our latest visit as medicines were still not being managed safely. In other areas of the service we saw that governance systems were being used to effectively monitor and improve standards, which meant overall governance and management was not consistently effective.

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. Records showed that staff advocated on people’s behalf when dealing with healthcare partners, which helped ensure they received support that met their needs and choices. One healthcare partner told us, “The residents appeared happy, and content and the staff appeared knowledgeable and willing to seek advice.”

The provider did not consistently focus on continuous learning, innovation and improvement to ensure all aspects of the service were effective. Medicines management continued be unsafe despite this having been previously identified. Following our visit the provider engaged with healthcare partners for assistance in starting to address the issues we identified.