White Acres

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 changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the home.

This service scored 57 (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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The service had positive values, and staff were committed to supporting people well. However, these values were not consistently translated into practice. Communication difficulties, inconsistent approaches to care and delays in implementing agreed improvements meant staff were not always working towards the same clear direction. While staff spoke positively about their roles, some described the service as busy and at times stressful. Staff and relatives identified inconsistencies in how support was provided, particularly for people who relied on routine and structure to maintain their wellbeing. A relative told us they could often tell which staff were on shift based on their family member's mood and presentation. We also found tasks were delegated to staff without sufficient guidance, which resulted in them not always being completed correctly.

This meant a consistent and positive culture was not fully embedded across the service. People were at risk of receiving inconsistent support and experiencing avoidable distress, particularly where their care depended on staff following agreed approaches and routines.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

The registered manager was caring, committed and receptive to feedback. However, the provider had not ensured they had sufficient time away from direct care duties to carry out their management responsibilities effectively, which had limited their opportunity to oversee the quality and safety of the service. The provider had now allocated the registered manager full-time, office-based management hours, and they were developing plans to address the concerns identified and strengthen their oversight of the service.

Staff felt able to speak up, but they did not always feel listened to. Staff told us they did not consistently receive feedback about actions taken in response to concerns they had raised or see evidence that improvements had been made. This reduced opportunities for learning and improvement to be shared across the service and limited staff confidence that their views would lead to positive change.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

Management systems and audits did not provide effective oversight of the service. They had not identified or resolved significant concerns relating to medicines, safeguarding, legal conditions, food and fluids, and record keeping.

During the inspection, the registered manager was responsive to feedback. They took action to resolve the concerns we raised about night staff not having medicines training by ensuring the completion of this training, and utilising night staff who were trained in medicines from neighbouring services. The registered manager also made a start creating Positive Behaviour Support plans, told us about the new folders they will implement which will contain important records for easy access such as hospital passports, updated communication passports and hospital grab sheets, and also implemented an audit to monitor the usage and effectiveness of 1 to 1 support hours. The registered manager told us they enjoyed working at the service, and demonstrated determination to make improvements across the service.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The provider had not ensured lessons were consistently learned when concerns were identified. Several issues had remained unresolved for extended periods, and we found missed opportunities to improve the quality and safety of people's care. Although the registered manager had recently moved into a full-time management role and had started to develop actions to address these concerns, the improvements were at an early stage and had not yet become embedded within the service.