Acorn Lodge Residential 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 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.

This service scored 62 (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 provider’s vision was, “To enhance the quality of life of every individual we support, ensuring they feel at home, supported, and confident in the care they receive.” From observations during inspection and conversations with managers and staff, it was evident this was embedded within the service. When asked what they most liked about working at the home, a staff member said, “I like the supportive team, caring environment and the opportunity to provide good person-centred care to [people].”

Staff member’s induction checklists included information about people’s rights, to ensure new staff understood the culture and followed the home’s values. The code of conduct for social care staff was included in the staff handbook.

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.

Staff confirmed the manager had the right skills and experience, and addressed concerns within the service in a timely manner. A staff member told us, “[Manager] is very loving and caring, it’s all about the residents. She is responsive to issues, absolutely.”

During our visit, the manager evidenced a strong presence within the service and confirmed they carried out a range of hands-on care and household tasks, leading by example.

The manager explained they were currently going through their registered manager registration with CQC, having submitted the application and undergone the necessary checks.

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

A question on staff surveys asked if staff felt able to approach managers with any concerns or problems, and staff we spoke to confirmed they were able to speak up. A staff member said, “Yes, if something is bothering me, I will say something.”

There was a whistleblowing policy which provided reassurance to staff about raising concerns. It said, “There is an open culture in the service which allows staff to feel supported to raise concerns without any fear of recrimination.”

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 recruitment policy considered legislation such as the Employment Rights Act 1996, Human Rights Act 1998 and Equality Act 2010 to ensure new staff were recruited fairly.

The provider’s employee handbook clearly outlined staff member’s rights, and the expectations of the role, to ensure staff were treated equally and their wellbeing was considered. It included specific information about flexible working, equal opportunities and harassment.

Staff supported each other and there was a positive and respectful culture at the home. A staff member told us, “Sometimes I give extra support to staff if they are struggling to understand (terminology). I will try to show them what I mean by providing pictures or prompts. I will show them how to cook different meals. They are happy to learn.” Another added, “I feel I am treated fairly and with respect. The team is supportive."

The provider had clear responsibilities, roles, systems of accountability and governance, but did not act on the best information about risk, performance and outcomes.

The provider had a variety of checks and audits in place to ensure governance and oversight, but these had not been effective at identifying and/or addressing concerns found during our inspection. For example, gaps to incident records, recruitment and training, and issues with fire safety and the environment. This presented a range of risks to people living at the home, staff and visitors.

There were arrangements for the availability and confidentiality of data and records, but the information was not always robust, or used effectively to monitor and improve the quality of care. Despite regular care plan reviews taking place, information in care plans and risk assessments was found to be lacking necessary detail about people’s health and care needs and had not been kept up to date when their need's changed.

The provider met with managers bi-monthly to discuss necessary improvements, areas for consideration and planned changes; and plans were in place to ensure business continuity in case of an emergency or adverse event.

Following feedback, additional audits and checks were introduced, including a more robust daily walkaround to capture any environmental issues. We saw evidence the level of detail in people's care plans and risk assessments was now more robust.

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 home worked closely with health and social care partners to improve people’s outcomes and quality of life. A social care partner said, “[Manager] is always learning more about processes to support people holistically.” Another added, “They are pro-active in addressing issues through collaborative working. They take initiative and respond to [people’s] care needs appropriately.”

The home had links within the local community, with the local church and day centre, though people opted out of attending regularly.

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

Whilst the provider had been responsive during the assessment process, they had missed opportunities to improve people’s safety by not always acting on information about risk prior to our visit. For example, by not always fully reviewing incidents to help prevent similar occurrences or reflecting on wider learning such as national safety alerts about environmental hazards.

There were examples which evidenced continuous learning and improvement to the quality of people’s care. A social care partner said, “[Manager] seems to always be responsive to advice and appears to be continuously working to improve the service and the experience of [people]. They seem committed to providing high quality care.”

The provider’s business plan outlined planned developments, designed to improve the home and ensure long term sustainability. The manager confirmed there was enough investment at the home to carry out ongoing improvements, and told us the provider was, “Supportive and helpful, and always on the end of the phone.”

Following feedback, an incident audit file was put in place to ensure systems to respond to and learn from incidents was more robust.