St Anne's Leeds Domiciliary Care 3 (DCA3)

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. This key question 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.

Staff understood their responsibilities and were committed to ensuring people received person-centred care in a safe, efficient way. A staff member said their core values were, “Dignity, person centred care, equality and respect.”

Relatives and others we spoke with consistently expressed the view that the service’s leadership was strong and dependable. A person told us, “I think St Annes are outstanding. St Annes always thrives to do better, and they are passionate and proud of what they do. It’s a life without limits.”

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.

Staff found leaders to be supportive, approachable and visible; the registered manager took a hands-on approach to supporting people who used the service and staff. Comments from staff included, “The managers have been the best managers I’ve had. They are supportive. They will sit down and talk with me” and “If we need anything they [Management] are always there. If I need to take short notice leave, they will let me do that.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff were confident in how to raise concerns and understood the whistleblowing process. They told us they felt able to speak up, that the management team listened to them, and that they had regular opportunities to communicate with the manager.

The provider actively recognised the emotional demands of care work. Staff surveys identified stress as a key theme. The provider responded with clear actions, including improving visibility of mental health support, increasing engagement with area managers, and introducing drop‑in sessions to allow staff to share concerns and ideas. These actions demonstrated a proactive response to staff feedback and a commitment to continuous improvement.

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. There were appropriate policies to support equality and diversity. Staff did not report any concerns and felt well supported. Staff had completed mandatory training in equality and diversity and had a policy in place which supported their understanding of how to promote inclusive practice and challenge discrimination.

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 auditing processes and governance systems in place to monitor the quality and safety of the service. Regular spot checks were also completed with staff to ensure they continued to meet the service’s expectations. These audits, systems and processes provided the registered manager with clear oversight of the service and people’s experiences. This meant the provider had effective mechanisms to identify issues, respond promptly to concerns and ensure people consistently received safe, high‑quality care.

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 provider worked with other healthcare professionals and shared information when required to help ensure outcomes were positive for people using the service.

The provider focused on continuous learning 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.

Leaders were committed to remaining up to date with current practice and guidance. The registered manager placed a strong emphasis on learning and innovation and demonstrated a clear passion for driving continuous improvement within the service. When challenges arose or things went wrong, they were open and transparent and took appropriate action to address any shortfalls.

A continuous improvement plan was in place to monitor progress and ensure any required developments were implemented. Since the last inspection, the provider had taken effective steps to strengthen the quality of the service.