St Anne's Community Services - York DCA

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 changed to 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.

There was a positive culture within the service, and staff were supported to provide consistent and person-centred care. The provider’s vision and values were communicated to staff through team meetings, supervisions and development reviews. They were discussed with staff, including the importance of the care provided and how this linked back to the provider’s visions and values.

Equality and diversity were promoted, and the management team ensured they were always available, approachable and visible within the service. The hands-on approach of the deputy manager had helped to shape the direction of the service, with one relative stating, “The deputy manager is there most days, contactable by the staff as often as they need to contact her, and easily accessible to them and to us as parents. This has been really beneficial."

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 management team were competent, visible and led by example. They were knowledgeable about issues and their priorities for improving the quality of the service.

The deputy manager led the service day to day, and they were well supported by the registered manager and senior management team. The deputy manager was knowledgeable and passionate about the service. Staff, relatives and professionals all spoke positively about the quality of the management of the service. Feedback included, “A lot has changed, the deputy manager has done fantastic, and the registered manager is in the service a lot more now too”, “The deputy manager is supportive, informative and approachable”, and “The deputy manager is there to oversee things. She is brilliant, she is on the ball with everything."

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

The management team operated an open-door policy and there were various channels for feedback to be raised. Staff and relatives felt comfortable and confident to speak up, and felt they were listened to. Staff told us, “I can go straight to the deputy or the registered manager. They are both approachable, they act on things we say and they listen.”

The management team welcomed feedback at any time, and feedback was actively encouraged in handovers, huddles, team meetings, supervisions and development reviews.

Professionals who worked with the service were offered feedback forms to complete. Relatives knew how to voice their thoughts and were similarly given regular opportunities to do so. The management team acted on feedback and worked with people, staff, relatives and professionals to improve the quality of care and experience for all.

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 provider promoted equal opportunities, and their workforce reflected a range of diverse backgrounds and experiences.

The provider had an Equality, Diversity, Inclusion and Wellbeing Officer, who led various groups and meetings. They consulted on policies and procedures to ensure fairness and inclusivity, provided human resources support, and communicated regularly with staff about current equality and diversity issues.
The provider distributed an annual diversity calendar highlighting religious events and national awareness days to promote cultural understanding and celebration.

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.

There were robust quality assurance processes and procedures in place. The management team had good oversight of the service. They completed regular and robust audits covering key areas, which included the quality-of-life tool. The audits were detailed and effective in identifying issues and where things could be improved. Where issues were identified, they were addressed through immediate feedback, measurable actions, huddles, staff mentoring, meetings and professional development reviews. The impact of the issues identified was considered, which supported meaningful actions in response. Actions were then monitored and reviewed to ensure completion and learning. Quality assurance took place at different management levels, which meant there was a strong culture of oversight within the service. One professional told us, “The service is well-managed with consistent oversight."

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. Professionals spoke about good communication with the service and effective sharing of information. The management team spoke about sharing their experiences with certain medical conditions with medical professionals, to support nation-wide learning about rare conditions.

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 had been a clear focus on learning and improving the service. As a result, the quality of the service had improved. One relative told us, “There have been vast improvements in the organisation, particularly around the support people are now getting. [Person] is getting out a lot more, doing more activities and enjoying themselves more.”

Staff and the management team were passionate about the service and had worked hard to ensure people received safe, person-centred and high quality care, which met their individual needs. There was a continued focus on the development of staff and the service, with meaningful and effective quality assurance processes now in place which supported continuous learning and improvement. Staff and the management team continued to have ideas and plans to further improve the experience of people using the service, and were committed to the ongoing positive development of the service.