Annefield Grange

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

We assessed all quality statements within the well-led key question. The service had a positive culture, with strong and inclusive leaders who led by example. There were clear systems and processes in place to manage and mitigate risk and to develop and improve the service. Staff understood their roles and responsibilities and were supported to speak up if they had ideas or concerns. Staff worked collaboratively with other services to improve people’s care and experience.

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 registered manager and/or deputy manager were present in the home every day of the week. This meant there was always management oversight of the service to be able to monitor and drive a positive culture. Staff were all positive about working in the service and felt that it was an inclusive and supportive environment for them and the people who lived there. They understood about all types of discrimination and felt confident that any concerns they raised about people's human rights would be addressed and resolved. One staff member said, "Everyone is respected here, we would never allow people to be discriminated against and if they were, I would report to the [registered] manager and she would do something.”

The provider had an equal opportunity policy and actively promoted an open and inclusive culture. We observed information available for people which supported them to live in the service without risk of discrimination.

The registered manager and provider's representative were both experienced and knowledgeable. They knew how to ensure care and support was provided to people that was safe, caring and responsive to their individual needs. They and the deputy manager were visible within the service and all staff we spoke with told us they felt able to raise any issues with them and were supported in their roles. One staff member said, "There is always a management person on shift; weekends as well, and they are really responsive. We [staff] can also email and share updates that way."

There were robust processes in place to ensure action was taken where needed and leaders were open to continual learning and development, to achieve positive outcomes for people. Audits completed and the 7 day a week management cover ensured leaders were able to respond to and address any priorities promptly. The registered manager and staff were skilled and knowledgeable about how to meet people's needs within a safe and inclusive culture.

All staff told us they knew how to raise concerns and were confident if they spoke to the management team, action would be taken. Throughout the inspection, the registered manager was open and transparent and described how they promoted an open culture where they wanted people, their relatives or staff to raise any concerns, so they could look at ways to resolve them.

The management team carried out regular staff surveys and analysed this to be able to take action where needed. They also completed surveys of people and their relatives’ views. They were open and transparent about any areas needing improvement and took prompt action to do so.

Staff told us they felt supported in their role and understood the different types of discrimination and what to do should they witness any. One staff member said, "The workplace here is open and residents [people] and staff would be accepted for who they are."

The registered manager described how they supported an open and inclusive culture for staff. There was an equal opportunities policy which identified how staff should work to ensure there is a fair and inclusive culture. This included reflection on practice to consider if anything needed to change and what could be learnt from people and staff members’ experiences.

People’s care records and all risk assessments and audits were on electronic systems, which enabled the management team to monitor and identify where action was needed. Records reviewed demonstrated this ensured good oversight of risks, systems and processes. The registered manager told us they had completed surveys with people, their relatives and staff in the last year. We saw the analysis of these surveys, which showed effective monitoring of people's lived experience was in place and action taken where needed.

The registered manager and provider had robust processes in place to ensure there was oversight and accountability of all systems. Information that providers are required to send to CQC and information sharing with external professionals were being completed as required, which helped ensure people received safe care.

People and their relatives told us they knew who the management team were and could speak to them about anything they wished to. One relative told us, "I feel confident I can always talk to the [registered] manager." Another said, "The positive attitude created by the management team, and employed by all members of staff, gives me peace of mind and confidence that my [relative] is in good hands." A third said, "The [registered] manager is very nice and very helpful."

There was positive partnership working between the staff and management at the service and external professionals. For example, they had regular contact with their local GP surgery and sought advice and support from speech and language therapists, the local hospice and mental health professionals. This meant partnership working was effective and ensured people had the right support they needed.

All external professionals we spoke with told us the staff team sought advice and support in a timely way, to meet the needs of people living in the service. One external professional said, " I have observed the [registered] manager and all staff are very kind and considerate to people. When I have requested feedback, all staff have been able to update me. I have also observed that if a staff member does not have the information, they will always get a senior member to support them. I have observed excellent communication skills between the staff."

There were clear processes in place to ensure staff raised any concerns or issues with the management team, who then sought external professionals input as needed. In emergency situations staff immediately contacted emergency medical professionals. There were regular conversations with people in residents’ meetings and support was given to people to speak with external professionals to review or assess their needs.

There was a learning culture within the home which meant staff, people and their relatives were encouraged to provide feedback about ideas and the development of the service. The management team had good communication skills and processes in place enabled them to monitor and review where improvement was needed and how they could achieve this. The management team were aware of best practice and actively encouraged staff to engage with learning and development, which meant better outcomes for people. One staff member said, "I feel like it’s a really good team here now. The [registered] manager is such a great support and has made me feel more confident and secure in my knowledge."

The registered manager kept up to date with best practice and told us they were supported by the provider to ensure they could deliver up to date care and support for people. They engaged positively and worked collaboratively with external professionals to ensure they could consider any improvements or innovation. There were clear processes for reviewing all accidents and incidents to ensure any learning was implemented and people's risk assessments and care plans updated when needed.