Tree Vale Limited Acorn House

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 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 good. At this assessment the rating has remained good.

This service scored 71 (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. For example, there was a clear and consistent approach across the service, with staff demonstrating a good understanding of the provider’s values through their practice. Policies, training and supervision reinforced expectations around equality, inclusion and respect for people’s rights.

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. For example, leaders were visible and approachable, and staff spoke positively about the support and guidance they received. There was clear oversight of the service, with leaders using their experience to make informed decisions and drive improvements. Records showed regular communication and engagement with staff, and a culture of openness where concerns could be raised and addressed appropriately.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. For example, staff and families described an open and supportive environment where views and concerns could be shared freely. Systems such as regular meetings, supervisions and feedback opportunities encouraged people and staff to speak up.

The provider promoted equality, diversity and inclusion within the workforce. They supported a fair and inclusive culture where staff felt valued.

Staff told us they felt well supported in their roles. The registered manager described how they took a flexible approach to support staff when needed.

The provider did not always have effective governance systems in place. Responsibilities, accountability and oversight were not always clear, and systems were not always used effectively to monitor risks, performance and outcomes.

There were systems in place to monitor and audit the quality of the service. However, these had not always identified the shortfalls we found, particularly in relation to the management of medicines.

The registered manager responded promptly to our feedback and took immediate action to investigate and address the issues identified. They began reviewing their processes to ensure they were more robust and able to identify risks, including those relating to medicines, in future.

The provider worked collaboratively with partners to support joined-up care and improve outcomes for people. Information and learning were shared to support continuous improvement.

The provider was open to support and committed to working in partnership. Staff told us they had positive working relationships with external services and were responsive to feedback.

The provider promoted continuous learning, improvement and innovation. They responded to feedback and took action to improve the quality of care and outcomes for people.

The provider was responsive to concerns and took timely action to address issues identified. Work had been undertaken to strengthen care plans and risk assessments to better reflect people’s needs.However, the provider recognised further improvement was needed in record keeping and to increase staff confidence in using the electronic care planning and daily care recording system.