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

Quality assurance audits and new checks were in place, but more time was needed to demonstrate the consistency and effectiveness of these systems. Further changes of management were due to take place so improvement was needed in relation to the consistency of leadership. Staff felt able to speak up about any concerns and the team worked in partnership with other organisations.

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.

Staff and leaders told us there had been work over the previous few months to improve the culture at the service. Work was still ongoing to ensure staff had a shared commitment to the changes and improvements at the service.

The provider had an agreed vision, purpose and values. These were available to staff and reiterated in the provider’s policies. Opportunities to discuss and reinforce these values collectively, via team meetings, had not happened frequently. The interim manager told us they planned to schedule team meetings monthly moving forwards.

The interim manager was knowledgeable and demonstrated a compassionate approach. Staff spoke positively about the management team and felt confident any questions or issues they had would be dealt with. However, there had been changes in management over the last year and the provider told us further changes were planned. These changes impacted on consistency of leadership.

Systems were in place to promote an inclusive working environment. There was an interim manager in post at the time of our assessment and senior managers visited regularly to offer support. However, long term management stability was needed to establish consistency and ensure improvements were embedded.

Staff told us they would feel confident speaking up and raising any concerns. They told us there were various ways they could get in touch with management to raise any issues, and they believed any concerns would be acted on. One staff member commented, “There is no problem raising any concerns, I’d feel very confident about this.”

A whistleblowing policy was in place and this was easily accessible to staff. There were various opportunities for staff to speak up.

Staff raised no concerns about equality and diversity and felt fairly treated by the provider. Staff said their views were usually listened to.

Recruitment policies and practices supported workforce equality and diversity. Staff received equality and diversity training and the provider supported staff with different learning styles.

The management team explained about new audits they had introduced and told us work was on-going to ensure consistency of governance and auditing systems. They recognised more time was needed to ensure improvements were embedded and sustained.

Information about incidents at the service were notified to CQC appropriately. There was a clear management structure and the provider had governance systems in place. However, these systems had not always been consistently applied over the previous year. More recently there was evidence that audits and the service’s risk register was being used better to drive improvements. There had also been work to improve records and incident reporting. More time was needed to demonstrate evidence of consistent, sustained progress.

People were referred to other services appropriately and professionals’ advice and recommendations were followed. People and relatives confirmed staff supported them to access facilities in the community.

Staff explained how they supported people to access services, activities and appointments, in line with their preferences. They were aware of other services and professionals involved and how to contact them.

The local authority told us the provider had worked with them to complete requirements in an action plan. A social care professional told us the interim manager had contributed very positively to joint working with a person and their family.

The provider had a number of organisational commitments including delivering social value to the community. The provider had appointed a number of ‘leads’ which supported involvement with partners and the oversight of this. People’s community activities and appointment outcomes were appropriately recorded.

Staff and leaders told us there had been recent improvements at the service and gave some examples of this. However, they acknowledged continued work was needed to sustain improvements. Staff said team meetings had not always happened regularly due to staffing challenges and difficulty getting everyone together. This had impacted on opportunities to share learning and discuss best practice.

Processes were in place to support learning and improvement. The service had a continual improvement plan, which they were working on. There were limited examples of innovation, as recent focus had been on ensuring core systems were in place and regulatory compliance achieved. There was opportunity to develop the service further and promote best practice. For instance, gathering people’s feedback more consistently to drive improvement.