Acacia Bank Care Home

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 assessment we rated this key question Inadequate. At this assessment the rating has changed to Good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff demonstrated a clear understanding of the values and vision of the service. They were able to articulate these values confidently and we observed them consistently embodying the culture and principles promoted by the leadership during our assessment. This was evident in their interactions with people and with each other, reflecting a positive and person-centred approach to care.

Staff meetings provided an inclusive forum where all team members were encouraged to contribute. Staff told us they felt comfortable raising concerns, sharing ideas, and discussing areas for improvement openly. This inclusive approach helped foster a culture of transparency and continuous development.

Overall, staff demonstrated a shared commitment to the service’s vision, which centred on delivering high-quality, respectful, and compassionate care. This alignment between leadership and staff contributed to a cohesive and motivated workforce, focused on achieving positive outcomes for people using the service.

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.

Staff, people living at the service, and their relatives all spoke very highly of the new manager. They described them as ‘approachable,’ ‘visible,’ and ‘actively involved’ within the service. The manager regularly engaged with both staff and residents, fostering open communication and a supportive atmosphere.

People and relatives told us they felt confident in raising any concerns or suggestions with the manager, knowing they would be listened to and acted upon. Staff valued the manager’s leadership style, describing them as supportive and encouraging, which contributed positively to team morale and motivation.

The manager’s presence and hands-on approach were viewed as integral to maintaining the positive culture within the service and driving continuous improvements in care quality.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff were confident in their understanding of the service’s speak up protocols. They told us they felt able to raise concerns without fear of negative consequences and trusted that any issues brought to the attention of leadership would be taken seriously and addressed appropriately.

This confidence in the whistleblowing and speak up processes contributed to an open and transparent culture where staff felt empowered to speak out in the best interests of people using the service.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Recruitment processes were effective in promoting a diverse workforce, with a clear emphasis on equality and diversity throughout the employment pathway. The provider demonstrated a commitment to fair and inclusive recruitment practices, helping to ensure that staff from a variety of backgrounds were welcomed and valued within the service.

Staff told us they felt they were treated fairly and equally, with no concerns raised about discrimination or unfair treatment. They reported a positive working environment where respect for diversity was embedded in everyday practice.

Particularly notable was the experience of night staff, who described the culture as fair and equitable. They felt their contributions were recognised and appreciated by the management team, which fostered a strong sense of morale and inclusion across all shifts.

The provider did not always have effective systems to ensure governance processes were successfully and accurately implemented.

Routine audits were being completed as expected; however, some shortfalls were identified that could pose risks if not addressed before new residents are admitted.

For example, the service’s action plan indicated that PRN (as-needed) medication protocols were in place. However, audits and reviews failed to identify that several PRN protocols allowed for variable doses that were not sufficiently detailed, potentially impacting safe medication administration.

Additionally, the monthly audit report for June 2025 highlighted that specific health-related care plans had not been created at the time of the audit, and these remained outstanding during the inspection, particularly relating to medication management.

More robust and thorough checks needed to be carried out by trained and competent staff when completing audits to ensure all documentation and protocols were accurate and complete.

Addressing these governance gaps is essential to ensure the service consistently meets regulatory requirements and that systems and processes remain effective in supporting the service as it grows.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Partnerships and communities were well established, with good evidence of active links to local community groups and organisations. The service supported people to engage with activities and events both inside and outside of the service, promoting social inclusion and enhancing their wellbeing.

Care records demonstrated effective partnership working with a range of healthcare and social care professionals. This collaborative approach ensured people’s care was well coordinated and responsive to their changing needs.

These strong community connections and professional partnerships contributed positively to people’s quality of life and supported a holistic approach to their care and support.

The provider focused on continuous learning, innovation and improvement across the organisation and local system.

The provider demonstrated a positive approach to learning and continuous improvement. We saw clear examples of information sharing and dissemination of best practice across the wider provider group. This included regular communication and collaboration between services to promote high standards of care.

Lessons learned from incidents, near misses and safety events were effectively shared across the organisation, ensuring improvements were implemented promptly. This commitment to collective learning helped to drive ongoing development and enhance the quality and safety of care delivered within the service.