St Anne's Court

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 inspection we rated this key question good. At this inspection the rating has changed to requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

We have identified a breach of legal regulation in relation to good governance. The provider had failed to ensure governance systems were established and operating effectively and they had not identified the shortfalls found during this inspection. This had placed people at risk of avoidable harm.

This service scored 61 (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 did not always have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.Systems and processes were not always established to ensure the service understood their direction. For example, this meant they did not always have clearly defined outcomes set for the service and therefore did not identify the shortfalls we found during this inspection. Although staff told us they worked as a team and were supportive of each other, there was limited direction. We discussed this with the registered manager who understood the need to establish a clear direction to always ensure safety, quality and improvement.

Leaders did not always understand the context in which the service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation as this had not been clearly defined. Leaders did not always have the understanding and oversight to lead effectively. The registered manager did not always share an understanding of the risks and issues facing the service and was not always clear about their responsibilities. For example, the registered manager had failed to identify the reporting of incidents, risks, issues and concerns was unreliable or inconsistent. We raised this with the manager and registered manager during the inspection, and they informed us about proposed improvements. We did receive positive feedback from staff about the kind and compassionate approach of the management team. Some of the comments were: “I have had a lot of conversations with the manager who knows their staff and residents well”, “The manager really cares about the residents”, “The registered manager and manager are very welcoming.”

The service fostered a positive culture where people felt they could speak up and their voice would be heard.People and their relatives told us they were happy to speak with staff, the registered manager or manager to address any concerns. Staff felt comfortable raising concerns, they knew how to speak up and had confidence they would be supported. The manager told us they dealt with any issues and concerns to ensure they were fully addressed. Records confirmed actions were taken where necessary.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. Staff told us they felt included as part of a team; they referred to each other as ‘family.’ Many of the staff had long service and were complimentary about the approach and acceptance of the manager. Records showed consideration of differences and individuality. The provider’s improved policies and procedures were all underpinned by equality and inclusion.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Governance, management and accountability arrangements were not reliable, consistent or operating effectively. Quality assurance arrangements were not applied consistently and were ineffective. For example, policies and procedures were not always personalised to the service. Processes were not in place to ensure sustainable and dedicated management of the service. Systems to ensure oversight of the service by the provider were not always established. We discussed this with the provider who told us they had secured support to create a process for scrutiny and oversight at provider level.

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. People told us they felt involved in their local community and there were communal opportunities to make friends and relationships within the service. The manager and staff consistently told us they worked effectively with external professionals. Staff shared information and worked with a wide range of professionals and services. We received positive feedback from partners who worked alongside the service. A health and social care professional said, “We have a very good working relationship.” Information was shared in person, via email and by telephone.

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. Systems and processes to ensure the service identified areas for advancement and continually worked to improve outcomes, were not always established. Audits schedules to monitor the quality and safety of the service were inconsistent, repetitive and often incomplete. We identified several audits of the service which were incomplete or inconsistent, the outcomes were not used to drive continuous improvement. For example, the service had sought feedback from people, relatives and staff but this had not always been used to shape the service and inform change. We discussed our findings with the registered manager, they told us they were accepting of our findings in relation to the shortfalls and told us they were working to establish systems for learning, along with strengthening of the overall governance systems.