Annex Abbey 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. This is the first assessment for this service since registration in November 2024. 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 registered manager supported staff to deliver high quality care and support to people in line with the provider’s values. They encouraged staff to read and understand care plans and focus on people’s individual needs. They also checked that people were happy with staff and felt comfortable with the care they received. Staff received training, support, and had access to policies and procedures to help them work effectively. The registered manager used audits, supervision, and team meetings to make sure staff understood and followed the provider’s values through their working practices.

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 registered manager was passionate about their role and committed to ensuring that people at the service received high quality, safe care. They undertook continuous learning and development to maintain their skills and knowledge. People, staff and healthcare professionals spoke highly of them. A relative told us, “They are inclusive and welcoming and that stands out for me.” A healthcare professional said, “Staff have shown incredible dedication, in particular the care home manager for her exceptional work in ensuring the smooth running of the care home…management is transparent, responsive, and always keep family members and healthcare professionals informed.”

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

The registered manager ensured people could raise concerns safely and without fear of consequences. Regular residents’ meetings and key worker sessions allowed people to share feedback. People’s representatives were also asked for their views, and staff checked in daily with people and recorded any concerns. Staff felt able to raise issues, and the service used feedback forms and suggestion boxes to help people and others give their feedback.

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 treated fairly and equally at work. They received training on equality, inclusivity, and fairness, and had the same opportunities for learning and career development. A staff member told us, “The support from managers is good. We are treated equally and fairly. We have different cultures, but we are all treated equal.”

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.

Governance systems were effective. The registered manager carried out regular checks and audits to monitor the quality and safety of care and support provided to people. Findings from these were used to identify areas for improvement, make necessary changes and support staff to improve their practice. The registered manager demonstrated understanding of regulatory requirements and their responsibilities, including providing accurate information, offering suitable support, and applying the duty of candour where appropriate.

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.

Staff worked well with healthcare partners to collaborate on the delivery of safe, high quality care to people. They followed guidance and recommendations from partners, to support the delivery of people’s care and support. A healthcare professional told us, “We have a good, positive working relationship with management.” Another professional said, “There is a very good, professional relationship.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system.

Arrangements were in place to obtain feedback from people, their friends and families, and staff, to help the service learn and improve. A relative told us, “The staff are always welcoming and friendly. They ask us for our opinions.” A staff member said, “We are encouraged to give our suggestions on how things can be improved.” Feedback, alongside the outcomes of audits, checks, and lessons learned from safety events, was used to improve the quality and safety of the care and support provided to people.

The provider was proactive in identifying ways to continually improve the service. Following our site visit, arrangements were made for staff to access a new employee assistance programme, which they could contact at any time for confidential advice and support regarding personal or work-related issues that may affect their wellbeing or work performance.