Acacia House - Peterborough

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. The culture at the service was positive and the management team understood the importance of aligning the care services values with CQC’s ’Right support, right care, right culture’ guidance. The management team had a clear vision for the service, and this was shared with the staff team.

The care service was homely and nicely decorated and people’s rooms were personalised to reflect their interests. Observations showed that staff respected the service as people’s home and people chose how they wanted to spend their time. The manager told us they were, “Encouraging the staff to think more outside the box, use more initiative, more positive risk taking regarding a meaningful life that promotes people's goals.” They went onto tell us how they were working on this care service and their sister home becoming more integrated. This included a recent joint party for people who wished to take part. They also told us how they were encouraging 2 people from the different services to attend an activity together to help them make friends should they choose to do so. A family member said, “They took him to [named seaside town] a few weeks ago…After his fish and chips he actually went in the arcades, he's never done that before and he's putting money in, so that was a new experience. Definitely bringing him out a little bit.”

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. However, this provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations. At the time of our assessment there was no registered manager in post.

Staff gave positive feedback on the management team at the service. They told us the management team were approachable and that communication was good. A staff member said, “Yes, they lead by example, especially [named manager]. Any issues of poor culture are addressed.”

The management team understood their regulatory responsibilities and were taking action to improve the service where necessary.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Relatives told us they knew how to raise concerns but had had no reason to do so. A relative said, “Well, if I have got a complaint, I go to the manager first anyway, but I've never had to do it.”

The manager told us about the provider forum and workshops that encouraged staff to get together to discuss initiatives. Staff could also meet with the providers Chief Executive team should they choose to do so.

Staff told us they felt supported by the manager and could raise suggestions or concerns. Staff understood the values of the service, and that their role was to also make the people who used the service feel cared for, respected and valued. Staff said, “Yeah. If there is anything wrong in your workplace, don't be scared, talk about it. Yes, we are encouraged to do this.” And “My experience is that the manager is here for the staff and helps them feel comfortable and is here for the service users as well.”

The manager told us that they were looking at different ways to engage people, their relatives and representatives more formally in feeding back on the service. This was because the number of responses to surveys requesting feedback on the service could be improved.

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. There was a diverse staff team at the service and staff told us they enjoyed working there. A staff member said, “I am happy working here. It's a hard job with responsibility but yeah happy.” Another told us, “I feel my managers are approachable and if I need support re personal issues (example given) they are flexible.”

The provider supported staff equality and staff told us they were encouraged to be involved in the service and discussions such as updating people’s care records. The provider’s recruitment was equitable and fair.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. However, during this assessment we found errors in staff recording of their daily tasks when supporting people. The area manager had found during an audit prior to this assessment that staff recording required improvement. Improvements were being actioned; however, it is too soon to confirm that the improvements needed have been fully embedded and would be sustained at the time of this assessment.

The management team had a good oversight of the service and risk, including the quality of people’s care and support. They completed daily, weekly and monthly quality and compliance checks. This included the auditing of safe medicines management, and safety checks including fire safety and equipment checks. Actions were taken when improvements were required.

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. The management and staff team understood the importance of and worked together with health and social care professionals and local authorities.

The manager was working with staff to encourage and promote people, should they choose to do so, be part of their community and take part in their interests and activities. A relative confirmed, “They took him to the pictures few weeks ago, they said it went well.” And “Well, they take him out, they've got a minibus that they are all insured to drive, and they take them out to various places. They go to [named restaurant] and places like that. They've recently got a new manager who's quite keen on getting them all out.”

The provider focused on continuous learning, innovation and improvement. The management team had a service improvement plan in place based on the findings from internal and external audits and monitoring of the service. Actions were recorded where required and monitored to help ensure that areas of improvement required were implemented to enhance the quality of the service provided to people.

Staff told us that they were encouraged to be involved in discussions on how to improve the service for people. A staff member said, “Managers always asking if we have any ideas or suggestions, any new activities for the guys.”