St Anne's Care Home

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 good. At this assessment the rating has remained good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance at the service.

This service scored 64 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a shared vision, strategy and culture. This was based on transparency and understanding challenges and the needs of people and their communities.

Staff knew people well and spoke knowledgeably about the people they supported. Staff told us they felt proud working for the service.

There was a want to continue driving improvements within the home and an emphasis on this being a holistic approach and team effort.

We received mixed feedback from staff regarding the leadership and how accessible the management was.

Relatives were complimentary about the management of the service. One relative said, “Management is good. St Anne’s is a small old home and it’s not always easy to do what they would like to be able to do but they manage with what they have.” Another relative told us, “From my observations so far, I do feel the home is well managed. The registered manager is very present, I particularly like that they are in constant communication with the care staff on the floor and not in their office behind a closed door. The registered manager is approachable and has a calm friendly manner.”

A health and social care professional said, “I have a very positive rapport with the registered manager, who is kind, professional and committed to [person’s] best interests. The registered manager has built an excellent relationship with [person] and has been very supportive during recent challenges.”

Some staff said they felt the management team was approachable, however others did not. Comments included, “I do feel supported and appreciated. They always have a positive and encouraging feedback which helps me to keep on going. They always support me with my concerns which helps me to perform my duties well”, “The registered manager is not consistently approachable at present, and opportunities for open communication have felt very limited”, “Approachability varies”, and “I feel inclusive behaviour is encouraged, although it may not always be consistent in every situation.”

The management team was open about the changes made within the service since the new registered manager started and was motivated to listen to staff feedback. Staff had access to an anonymous channel to provide feedback. Overall, recent survey results were positive and the management told us they were in the process of implementing actions from the survey.

The registered manager said, “We are nothing without our carers.”

Staff confirmed they knew how to whistle blow and felt they would be listened to. Staff told us they knew how to report concerns to external organisations if necessary. Comments included, “If an abuse has been found within the service I would whistle blow it to the line manager. If it’s outside, will contact the police”, “If I have a concern about a resident, I do not hesitate to raise it with management. I feel confident reporting anything that could affect a person’s wellbeing so it can be addressed appropriately”, and “I have a duty to immediately report any error that I spot to my management and appropriate authorities. In so doing I have duty a to prioritise patient safety.”

The service displayed a poster with information on how to contact external organisations, such as CQC and the local authority, if people or staff had concerns.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

Whilst some staff felt the management team were inclusive, others told us they did not feel valued. Comments included, “Management ensures our team is fair to everyone, regardless of background, and always addresses any inappropriate language or behaviour immediately. They encourage us to learn about and respect all the different cultures and preferences of the people we support and our colleagues”, “No issues or concerns. They always support me as a staff”, and “At times I may not always feel fully valued, but I continue to focus on providing the best care for the people we support.”

Staff confirmed the service made reasonable adjustments for them when required.

The service did not have clear systems of accountability or good governance.

Governance systems in place were not always used effectively to identify shortfalls found during this inspection. For example, the provider did not identify that some MCA assessments were not completed, and some were not reviewed in line with good practice.

The provider did not have an effective oversight of training requirements and failed to identify specialised training to administer 1 medicine to 1 person was out of date. This put people at increased risk of avoidable harm.

Services we regulate have a statutory responsibility to notify CQC about certain events that occur in a service.Eight notifications of outcome of an application to deprive a person of their liberty (DoLS) were not submitted to CQC as required.The registered manager submitted these retrospectively.

Following our inspection feedback, the registered manager implemented an improvement plan to address the identified shortfalls. The improvements made needed to be embedded into practice and sustained.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Staff told us they communicated with health and social care professionals as required.

A health and social care professional said, “Their communication with all parties has been positive and engaging and they have demonstrated real flexibility to promote and facilitate a good transition. So much so that they have been willing to send staff to spend time watching how the [professional] manage [person’s] needs, prior to the admission date, so they could witness the mannerism and techniques the [professional] used. This has been especially important for [person], who requires a very specific approach, in order to avoid intense periods of agitation.”

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The registered manager told us about the ways in which they were continually looking to improve the service and the work they had already done. This included quality assurance processes. These were not always effective at identifying areas of improvement we found during this inspection.The registered manager and provider were responsive during the inspection and reviewed the processes in place to ensure necessary changes were made and systems updated.