St Anns Healthcare - Main Office

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. This is the first assessment for this service. This key question has been rated 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 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.

The provider had a clear aim of providing a person-centred service which promoted people’s rights and independence, and these goals were shared with staff. Leadership culture was seen to be positive and proactive in recognising where some improvements were needed. The provider understood the needs of their local communities and were keen to develop the service to meet local needs.

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. They did so with integrity, openness and honesty.

The provider/registered manager was regularly at the service and supported by a small office-based staff team. Each person had a distinctive role within the organisation and understood their individual responsibilities. Staff we spoke with were all very positive about working for St Ann’s and they described the registered manager as approachable and responsive.

We also received positive feedback from an external professional about the registered manager and their contact with them. A staff member told us, “If I have any problems, I can contact the office and know they will help me.” One relative said, “I have no complaints and would highly recommend the company. I can contact them any time and find them very approachable.”

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

The service had created an environment where staff were able to speak up and raise concerns when needed. Regular meetings between the management team and staff took place. Staff were given opportunities to discuss performance via a supervision and appraisal process. Staff told us they could speak up about anything and were listened to and things 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.

The staff we spoke with spoke positively about their experiences of being recruited and working at St Ann’s. Staff told us they felt very supported by management team. At the time of the assessment 100% of the staff were from overseas. Staff told us they were treated in an inclusive way. The provider told us they wanted more diversity in their workforce but they had experienced difficulty with local recruitment due to the rural location and accessibility. People and their relatives told us they were very happy with the staff who cared for them.

The provider did not always have clear systems of good governance. They did not always identify areas of risk and effectively complete some records. The provider addressed and took action during the assessment to address any concerns we found.

The provider had a range of systems and processes for quality monitoring and auditing. However, areas of concern found during the assessment had not always been identified through the oversight systems and processes used. Some records used were not always accurate or current about people’s needs or risks associated with their care and treatment.

The provider had not always been submitted statutory notifications required by us. Although appropriate action had been taken and information shared with the local authority, we had not been formally notified about some safeguarding concerns. Some recruitment files had not been consistently completed, and no audits check on the files had been completed. The recording of best interest decisions and consents were not all completed in line with the MCA.

The providers processes for quality monitoring did not always make sure that medicines record keeping supported medicines administration to safely meet people’s individual needs, increasing the risk and potential for mistakes. The need for improvement in this area was not reflected in the recent medicines audits.

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.

There were systems in place to ensure the provider worked in partnership with other agencies, staff and people. The management team expressed an open positive attitude to receiving support and understood how and where they could access support. Relationships with the local GP practices and staff were seen to be working well together. The provider attended local forums for the providers of services locally.

The provider 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 contributed to safe, effective practice and research.

There was a drive for improvement and development by the provider evident during the assessment. The management team was keen to promote good practise and continuous development in the service. The training records showed some delays in staff completing essential and or refresher training. The provider responded immediately and made arrangements with an external training provider for this to be addressed. There were processes for seeking and reviewing feedback from people, family members and staff, and learning from accidents, incidents and complaints to ensure learning was implemented leading to overall service improvement.