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 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 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 and staff had a shared vision and culture based on listening, learning and trust. The management team were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally. There was a positive atmosphere and culture in the service which focused on effective care and support for people.

The management team were knowledgeable about their regulatory responsibilities and about the priorities for the development of the service.

Staff demonstrated an understanding 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 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 open and honest about the challenges they had faced and were positive about the improvements they had made.

Staff were positive about working for the provider and gave examples of staff development opportunities, such as training in the use of British Sign Language.

The provider fostered a positive culture where people 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.

The provider had policies and procedures in place regarding equality, diversity and inclusion and staff had received training on equality and diversity.

The provider 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 acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The management team had good oversight of the service and were supported in their roles by the provider. The provider had structures in place to monitor and improve the quality of care they delivered. Systems such as audits and quality monitoring were used to check the quality and safety of the service and actions noted to be in place to address issues highlighted.

The management team were aware of their responsibilities to notify partners. For example, notifications to CQC and safeguarding alerts.

The provider had a business continuity plan which detailed how they would be prepared for emergencies. The model of care met the CQC guidance for ‘Right Support, Right Care, Right Culture.’

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.

The management team had a strong commitment to improving the service and were open to suggestions for improvement, recognising the importance of joint working with partner agencies. Records seen evidenced positive working relationships with other professionals.

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.

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.

The management team was open to learning and improving. Learning was embedded through team meetings and audits, and the management team were continually striving to make improvements. The management team were responsive throughout the assessment to suggestions for improvements to ensure the person received safe and effective care.