Our Governance, Policies and Reports

Ensuring quality and safety

Ensuring our due diligence and adherence to legislation in respect to our services, please find below details of our Corporate Governance and our key policies

  • Corporate and Information Governance
  • Statutory Key Leads
  • Safeguarding
  • Our Policies
  • Our Reports


    St. Anne’s has a strong and robust governance framework developed around a collection of systems, processes, and controls all of which have been designed to provide high quality services which are safe, effective, and well managed.

    The Governance Office in Central Services is structured to deliver support across all areas of the governance spectrum enabling and empowering operational service delivery managers to provide high quality in an environment of continuous improvement. We have frameworks that are clear and effective and use a range of different tools, systems and channels of communication.

    All operational and support services teams receive direct support from the Quality and Continuous Improvement Team using a range of quality monitoring systems of control, tracking and improvement.

    Finally, our Governance Framework also provides all our employees and volunteers with a clear set of principles around how we operate, how we support people and how we work together to achieve the best outcomes.



    Information Governance

    St. Anne’s have three key members of the team undertaking specific areas of responsibility in protecting personal information. These are our ‘Caldicott Guardian’, our Senior Information Risk Officer, and our Data Protection Officer.

    Caldicott Guardian – Shona Beaton

    Shona has responsibility for ensuring that St. Anne’s uses information about people legally and appropriately, and that we maintain confidentiality. This includes personal information about the people we support, their relatives and people who work for us.

    As well as making sure that any systems and processes we use to store information about people are secure, the Caldicott[1] Guardian also helps to ensure that the right arrangements are in place if we need to share information with other organisations, for example those with responsibility for social care and safeguarding.

    The Guardian helps decide when confidential information might be used, and when it should not, by following what are called the eight ‘Caldicott Principles’.

    Senior Information Risk Officer Clynt Hall

    Clynt is our Senior Information Risk Officer (SIRO), this role has been created under the General Data Protection Regulations (GDPR). Clynt oversee policies, frameworks, and procedures to minimise risks to data.

    Data Protection Officer – Sara Otley

    Sara is our Data Protection Officer (DPO). It is a requirement of GDPR that St. Anne’s appoint a DPO. Sara makes sure that the organisation protects data, reviews and amends any data protection issues. Sara liaises with the Information Commissioner about any serious data incidents. Duties as DPO include:


    [1] Named after Dame Fiona Caldicott

    Statutory and Key Leads

    • Caldicott Guardian: Shona Beaton (Director of Operations, Deputy Chief Executive Officer)
    • Senior Information Risk Owner (SIRO): Clynt Hall (Chief Finance Officer)
    • Care Quality Commission Responsible Person: Shona Beaton (Director of Operations, Deputy Chief Executive Officer
    • Care Quality Commission Regulated Services: Registered Managers: Individual Service Managers are registered with CQC
    • Regulatory & Compliance, Risk Management, Health and Safety: Noreen Metcalf (Head of Corporate Governance)
    • Safeguarding: Azra Kirkby (Chief Executive Officer) Pauline Garnett (Trustee – Safeguarding Lead)
    • Data Protection Officer (DPO): Sara Otley (Information Governance Officer)
    • Speaking Up Lead: Named operational individual

    Managing risk from the context of safeguarding

    Safeguarding people and assets are everybody’s responsibility. At St. Anne’s we have a comprehensive programme of training, which includes safeguarding.

    • Everybody who is employed including agency staff, volunteers and Trustees of St. Anne’s undertakes mandatory online safeguarding adults and safeguarding children training prior to taking on a shift or beginning to work within the organisation.
    • Refresh & focused training: Further training is available in the form of refresher, and for specific types of work, for example Positive Behaviour Support training.
    • Trustees also undertake further strategic level risk management and safeguarding training in partnership with external experts.
    • Safeguarding lead: The safeguarding lead has undertaken Level 5 safeguarding training Adults, which is in line with the Intercollegiate Safeguarding Adults National Framework.

    Promotion of effective safeguarding practice is achieved through the following key roles and actions:

    • Safeguarding Supervision: Is provided to area managers by the Director of Quality.
    • Safeguarding Boards: Attendance and reporting by individuals.
    • Safeguarding Network events: Attendance at specific safeguarding networks and events encouraged and undertaken regularly by individuals who report back and share learning.
    • Executive Lead: A named executive lead is identified ‘Safeguarding Adults and Children’.
    • Trustee Lead: A named Trustee lead is identified ‘Safeguarding Adults and Children’.
    • Serious Safeguarding Reviews: Are attended by the Director of Quality.
    • Learning Disability Mortality Reviews (LeDeR): Are supported and as required are attended by First Line Managers.
    • Caldicott Guardian: Director of Quality is the named person.
    • Care Quality Commission (CQC) Nominated Person: Strategic level lead (sitting above Registered Managers). Responsible for upholding standards, responding to concerns and queries, and ensuring high level supervision of regulated activity and quality and safety.

    In addition, St Anne’s has a range of key policies and statements which include:

    • Safer Recruitment and Selection (including enhanced DBS checks)
    • Prevent Policy
    • Mental Capacity Policy
    • Deprivation of Liberties Policy
    • Safeguarding Adults & Safeguarding Children Policy
    • Modern Slavery
    • Whistleblowing Policy
    • Finance Delegation of Authorities Policy
    • Business Continuity Policy

    Other key documents that support the management of risks include:

    • Asset and contract register
    • Internal audits & Internal audit programme

    Equality and Inclusion Policy 2021

    Equality and Inclusion are woven throughout all that we do at St Anne’s and are…

    Modern Slavery and Human Trafficking

    Modern slavery encompasses slavery, human trafficking, forced labour and domestic servitude. St Anne’s is committed…

    Safeguarding Adults Policy & Procedures

    Our Safeguarding Adults Policy & Procedures

    Whistleblowing Policy

    Our Whistleblowing Policy

    Confidentiality and Data Protection

    Our Confidentiality and Data Protection policy

    Corporate Health and Safety

    Our Corporate Health and Safety policy

    Statutory Accounts 2018-19

    Each year we publish our statutory account, this is the report for 2018-19

    Statutory Account 2019-20

    Each year we publish our statutory account, this is the report for 2019-20

    Statutory Accounts 2017-18

    Each year we publish our statutory account, this is the report for 2017-18

    Gender Pay Gap Reporting 2021

    Gender pay gap legislation introduced in April 2017 requires all employers of 250 or more…

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