Acorn Lodge

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 requires improvement. At this assessment the rating has remained 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 service.

This service scored 61 (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. Regular meetings were held for people and their relatives to voice their opinions and share feedback. Minutes of the meetings were circulated for those who were unable to attend. We saw discussions were held regarding the menu, activities and upcoming events. A relative spoke about meetings and said, “We had a meeting to discuss what residents wanted to improve the place. I got the minutes. They decided to do a garden party and the outside area was improved.” People’s suggestions were listened to. Feedback surveys were circulated to people’s relatives, the results were positive and where suggestions were made they were actioned. There was a suggestion box in the entrance of the home so people and relatives could anonymously express their views.

Not all leaders understood the context in which the provider delivered care, treatment and support. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively. The registered manager was open and transparent throughout the inspection process and showed a will to make improvements where concerns were identified. However, there were gaps in the management’s knowledge in respect of when to refer concerns to the local authority safeguarding team and when to submit statutory notifications to CQC. We received positive feedback about the registered manager from people, relatives, staff and professionals. Some comments included, “I talk to [registered manager] all the time, they’re personable, quite strict and efficient. [Registered manager] wants to do well; they have made the home more professional and makes me welcome. In my view I think the home is very nicely managed. People are well respected and kept safe.” And, “The manager is very involved and shows genuine care for the safety of residents. We have collaborated well, and I have found that treatment plans are being implemented effectively by the team.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had a clear whistle-blowing policy to follow if they needed to speak up and raise concerns. Staff told us they felt comfortable to speak with their line managers if needed. A staff member told us, “[Registered manager] is always in the office busy but I can speak to them. Usually I speak to [deputy manager] and the director. We see [registered manager] if we have problems and need help, they sort out any problems.” Staff were issued feedback questionnaires about working at the service, they were able to remain anonymous if they wished. Following the survey the provider installed a suggestion box for staff, where appropriate, they read and addressed comments during staff meetings.

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. Staff told us they felt included and listened to. A staff member said, “I would like to say I am having a good time at Acorn Lodge, everybody is very supportive. If I need anything they will always help me.” Staff were from a range of diverse backgrounds, their protected characteristics were considered and arrangements were made for some staff to have a quiet area to practice their faith. The registered manager purchased separate fridges so staff could store their food in line with their cultural needs and preferences. Shift patterns were adjusted to suit staff’s family lives, including childcare arrangements. Regular staff meetings were held to enable staff to discuss agenda items and make suggestions in an open forum. Meetings were interactive and allowed staff to voice their opinions.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Quality assurance systems for people’s care records were in place, however, they did not identify where information was inconsistent or where assessments of risk had not been conducted. We reviewed care plan audits of May, June and July 2025 which highlighted that people’s care records were not person-centred. However, we identified since this time there had been no improvements. The registered manager did not hold a thorough oversight of all incidents and accidents within the service. Following our review of the ‘dashboard’ on the electronic care management system (ECM), we identified injuries where the origin was unknown. The registered manager had not viewed the dashboard and was unable to locate incident forms to investigate how the injury happened and mitigate risks of reoccurrence. We identified further gaps where staff had not documented discussions with professionals. These included outcomes from the speech and language therapists following a choking incident, referrals to the falls prevention team and advice following physical interventions between people who used the service. We reviewed a person’s activity log which showed no social engagement for 9 consecutive days; processes had not picked up these gaps in recording. Reviews and checks of staff recruitment files had failed to highlight that gaps of employment histories had not been explored and documented.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. However, they did not always share information and learning from partners for improvement. Staff and managers mostly worked well with partners in care, a visiting health professional told us, “I work with the home manager, deputy manager and trained nurses. They have an open-door policy. I have never been informed that there is no one to support information for my visit, mainly arranged. The manager is visible within the floor at times talking to patients. The deputy manager knows their patients so well individually and will update me at times with information then back it up by accessing the patient’s file to further read.” Although we received positive feedback, we identified occasions where advice and instructions had not been updated in people’s care records.

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. Despite the checks on care records, recruitment files and incidents and accidents not being effective, other quality assurance processes worked well. For example, medicine audits and checks on infection prevention and control identified areas for ongoing improvements, findings were included on the service’s future improvement plan which specified target dates. The registered manager told us how they had identified gaps in staff knowledge in respect of care planning and completing daily notes on the ECM. They had arranged for the ECM provider to provide some additional training for staff. The registered manager had linked with other local care homes to share learning and provide mutual support; this included working with local health care professionals to facilitate and attend local care homes for various training courses.