Acre Care Limited

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 good. At this assessment the rating has remained 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 68 (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.

The service had a positive culture. Staff were consistent in their view that this was a good provider to work for. Staff described the provider’s vision was to offer a personalised service, and spoke proudly of the service that people received. One staff member said, “All the staff want to do the best for people, we provide a very good service, it’s very personalised for individuals.” People described a positive culture. One person said, “The staff are happy. They come through the door with a smile on their face.” The registered manager told us, “Staff retention is good, they usually stay, they enjoy working here.”

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.

People, their relatives and staff spoke positively about the leadership of the service. One person said, “If I have any concerns I ring (registered manager).” A relative said all the office-based staff were helpful, they told us, “I will mention things to them, and then it is sorted.” We observed staff in the office taking phone calls from people and their relatives. We noted calls were answered quickly and issues were dealt with effectively.

Staff were consistent in their view that the registered manager was supportive and easy to talk to. One staff member said, “I have received great support, the manager is very easy to get on with, they deal with any concerns really quickly.” Another staff member said, “If you have any concerns the manager will book an extra supervision meeting, I feel very well supported by her.”

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

Staff told us they were able to raise any concerns, and they were confident that actions would be taken. One staff member said, “I never worry about speaking up. The manager will sort things straight away. For example, I was not happy with my rota, the issue was sorted straight away.”

People and their relatives said they knew how to raise any concerns and were aware of the provider’s complaints process. Staff told us complaints or concerns were usually dealt with straight away and therefore few complaints were recorded. One complaint was noted, and the registered manager had taken immediate actions to ensure the matter was investigated quickly and thoroughly.

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.

The provider had recruited a diverse workforce and promoted a fair and equitable culture. Staff told us they felt well supported and described how their individual needs and skills were considered and appreciated. One staff member told us English was not their first language. They explained how they were allocated to work with a person who spoke the same language. They described how this benefitted the person by helping to build trust so they felt comfortable with their care. Another staff member described how the provider had been flexible and supportive to them, considering their personal circumstances and making adjustments to enable them to continue working. Staff spoke positively about being part of a team where they felt supported and included.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

There was a lack of oversight and governance in some areas of the service. The registered manager was required to have oversight of incident and accident reports submitted by care workers. Not all incident reports had been investigated and completed by the registered manager. The provider’s systems for governance had not identified this shortfall. This meant the provider could not be assured that appropriate care had been provided or that measures were identified and established to prevent further occurrences.

Systems for reviewing risk assessments and care plans were not consistent. For example, some omissions in care records were not identified, including where there was no risk assessment or care plan in place for a health condition. The provider’s policy for medicine administration required there to be a protocol in place for any medicine that was prescribed PRN (as required). Audits of medicine administration and MAR charts had not identified that PRN protocols were not always in place. This meant staff did not always have all the information they needed. We did not identify any negative impact for people, however there were potential risks due to these omissions. The provider’s checks and audits had failed to identify these shortfalls in records, and this was an area of practice that needed to improve.

Following this assessment the registered manager told us how immediate actions had been taken and governance systems had been improved to address these shortfalls in records.

There were robust policies and procedures in place to guide staff in delivering safe and effective care. Staff understood their roles and responsibilities. Managers monitored the quality of the service and staff performance with regular support visits.

There were contingency plans in place for emergencies. This included a system to identify people for whom the service was critical. This meant the provider could be assured staff would know which visits to prioritise in an emergency situation.

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.

Staff described working in partnership with health and care professionals to ensure a seamless service for people. One person had been referred to an Occupational Therapist (OT) and equipment was prescribed to help them move around. The OT showed some staff how to use the equipment safely and made a video for other staff. This meant all the staff who supported the person knew how to operate the equipment safely and in the way the person preferred. The person’s care records reflected the advice provided by the OT. Staff described effective communication with health care professionals, and this was evident within care records that we sampled.

People told us staff were proactive in supporting them to stay connected within their local community and networks. For example, one person told us, “Last week the carers came for a bit longer so they could take me to church.” A relative described how the provider had been flexible with visit times and support, to enable a person to attend a wedding.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

Not all incident reports had been completed and there was a lack of systems to support effective data collection. This meant there was a failure to identify patterns, trends and learning from incidents. For example, the registered manager was not able to identify data that explained how many incidents had occurred, or what the nature of the incidents was.

Visits to people were planned with an electronic call monitoring system. The provider did not have a system in place to check that all visits had happened as planned. The registered manager, staff and people who used the service told us the service was reliable and there had been no missed visits. However, following this assessment, the registered manager told us how they had identified a way to gain this information electronically on the call monitoring system. This improvement would provide additional assurance that no visits had been missed.

The registered manager told us about plans to make improvements to other systems, including for managing training for staff members. They described how this would provide more effective data and would support them to have better oversight of staff training.