St Andrew's Healthcare - 17 The Avenue

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 newly registered service. This key question has been rated 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 breach of legal regulation in relation to governance at the service.

This service scored 62 (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 management team had a shared vision of how the service needed to be developed and plans had started to be implemented. The recruitment of additional permanent staff was a priority and this process had started. The management team supported staff in promoting a positive, transparent and inclusive service that enabled staff to raise any concerns or issues.

Staff feedback was overall positive and where concerns about consistency and continuity of staff were raised, this was known by the management team and was being addressed.

Staff demonstrated an understating of the provider’s vision and values in supporting people in their care journey to further develop their independence and lead active and fulfilling lives. This included accessing support from British Sign Language interpreters, receiving support from deaf staff and staff also trained in British Sign Language.

The provider's policies were in line with current best practice, but we found they were not always followed in relation to medicines management, infection prevention and control practice, food safety, data protection, staff recruitment.

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.

Leaders were visible in the service, approachable and accessible for the person and staff.

The management team had the required experience, skills and knowledge to manage and lead the service. During the inspection they were found to be open and honest about the areas that needed development and were receptive to additional areas identified during the inspection that needed improving.

Staff were positive about working for the provider and gave examples of staff development opportunities, such as progression to positions with greater responsibility. A staff member said, “I receive supervision every month, we also have staff meetings monthly, communication procedures are helpful and supportive. The provider is a big establishment that provides room for personal development, and I enjoy working here.”

The provider fostered a positive culture where the person felt they could speak up and their voice would be heard. Staff were aware of the provider’s policies and procedures that supported them to raise any issues relating to poor practice, concerns and complaints.

Staff told us they felt confident they could use these procedures, and they would be listened to, and managers would take action. Management meeting records confirmed actions taken to concerns raised by staff.

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 were overall positive about working for the provider and the management and leadership of the management team. Staff confirmed they were respected and treated equally. We were aware staff recruitment was ongoing and how the provider was proactive of recruiting staff with a protected characteristic.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes.

The provider’s systems and processes to assess, monitor and mitigate risks were not sufficiently robust or fully effective. The provider’s policies and procedures were not consistently followed to ensure people’s safety. Risks were identified in relation to medicines management, infection prevention and control, food safety and recruitment procedures. The provider’s audits and monitoring procedures had failed to effectively identify shortfalls in the fundamental care standards identified during this inspection.

Where internal procedures had identified some areas for improvement, there was a lack of robust actions, follow up and oversight by the management team. However, the management team had started to identify areas for improvement and an action plan and new and improved systems and processes were being implemented. Further time was required for these to become fully embedded and sustained.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for the person. They shared information and learning with partners and collaborated for improvement.

Staff worked closely with external health and social care professionals to ensure the person’s individual care and support needs were fully known, understood and met by staff.

Feedback from external professionals were positive. One professional described partnership working as, “Excellent.”

The provider’s systems and processes were not fully robust and effective in relation to continued learning, improvement and innovation.

The management team were aware improvements were required and had begun to take actions to address this. For example, new auditing procedures used to assess, review, monitor and make improvements were being implemented.

New management roles had been developed to enhance the oversight and leadership of the service. However, further time was required for new and improved systems and processes to become fully embedded and sustained.