Little 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 service was not consistently managed and well-led. However, leaders and the culture they created promoted 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.

We observed practice and reviewed documentation which evidenced the culture at Little Acres ensured each individual person was at the centre of their support when decisions about their lives were being made and staff worked as a team to achieve this.

The registered manager understood the importance of fostering a positive and open culture at the service, the potential negative impact a poor culture could have on people and took measures to oversee this including regularly walking around the home to observe.

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 openness and honesty.

We spoke with members of staff and the management team who talked passionately about their role and wanting to make a difference in people’s lives which we observed in practice. The staff we spoke with supported that the registered manager had the skills, knowledge and capability to lead the team. One staff member said, “I feel valued, this is clear from my appraisals. If I need anything or have any problems the management team are always there to support me”.

The registered manager spoke about the support she received and the network of support from other areas of the organisation. Throughout the assessment the registered manager and staff team were honest and open to feedback.

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

People and relatives were seen to be able to openly communicate with staff and management and the staff team had positive relationships with people. Relatives knew how to raise a concern, and staff told us they felt confident speaking with management about any concerns.

There was a current policy and procedure to support staff to speak up and staff told us they felt able and had opportunity to discuss concerns. One staff member told us, “Yes, I feel able to speak up about concerns I may have. The manager has an open-door policy and is always ready to listen to any concerns we have. They are sometimes addressed in the staff meetings we have, or with the relevant people.” The registered manager worked in a way that supported people to be able to speak up, they said, “It depends on having that partnership working with staff and they feel concerns are valid and they are allowed to have a voice.”

People feeling able to speak openly about concerns and issues meant issues could be identified and addressed quickly.

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 an appropriate policy in place and staff received training on equality, diversity and inclusion to raise awareness and promote an inclusive culture in the home.

No one raised any concerns regarding workforce equality, diversity and inclusion during the assessment.

The provider had clear responsibilities, roles, systems of accountability and good governance. However, governance processes were not consistently used effectively to manage and deliver good quality care and treatment.

The provider had defined roles and responsibilities, and staff were clear about this. The registered manager and leadership team understood their responsibilities in assuring good quality care and the governance processes used but these had failed to identify concerns with medicines management. The management team had identified some areas for improvement which were in the process of being actioned however, the audits and management checks had failed to identify the issues found during the assessment.  

The processes in place supported with the good governance of the service and people receiving good quality care required further focus and development to ensure they were effective.

The model of care used at the home was in line with current best practice guidance right support, right care, right culture. People had appropriate accommodation and lived with people who were compatible, so they did not have to change their lives to suit others which enabled them to live the life they chose.

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.

We saw examples of engagement with other professionals to ensure people received holistic care that met all their health and wellbeing needs. Management and the staff knew what stakeholders were available to the service and how to access support. Leaders worked with people, their representatives and staff to build a culture that focused on enabling people to enjoy their lives.

We saw the provider engaged others so people could thrive, have new experiences and live the life they choose, for example, accessing community resources like day services.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

We spoke with the registered manager about continual learning, improvement and innovation and they provided examples of how they had reviewed incidents and concerns and identified improvements which were shared with the team. They also spoke about the implementation of new digital systems and devices for recording care plans and daily records and how this has supported people’s engagement in their care. They said, “Residents like to be more involved, [name] likes to take pictures from the device, so they are able to have more involvement in their own care notes and records.”

The registered manager had taken on board quality concerns raised during the assessment and was committed to making improvements at Little Acres to avoid a recurrence. They said, “When I came here there was a lot I felt wasn’t right. I feel over the last 5 years we have done a lot of work, but there’s still room for improvement.”