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 inspection we rated this key question requires improvement. At this inspection the rating has changed to 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 75 (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. People were able to provide feedback through meetings and surveys, the registered manager completed service ‘walk rounds’ to ensure they captured people’s views or address any issues they may have. A suggestion box was available so people or relatives could provide ad hoc feedback or remain anonymous. People told us they were included and could express their views. A person commented, “I would talk to the one in charge I'm sure they'll sort everything out.” A relative said, “I’ve not been able to attend (meetings). I’ve been busy. I’ve had survey forms and made honest comments on them. They dealt with my concerns about smells straight away.” Some relatives told us they were mostly kept up to date with changes in needs and support, however, had limited involvement with care planning. A relative told us, “[Person] has a care plan. I’ve never actually seen it. I don’t believe we were involved. I was told the care plan was going to be changed. I presume social services were involved.” The registered manager and nurses had held some care planning reviews with relatives and had plans to continue this with all relevant relatives or representatives.

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. Improvements had been made with reporting and escalating concerns to the local authority and the registered manager now notified CQC of all reportable events within the service. The registered manager shared imminent plans for the service which included the appointment of an additional manager. This appointment was to support the general oversight of clinical and operational matters. The registered manager had been supported by the provider and a business support worker from the provider’s head office. Staff told us and meeting minutes confirmed the registered manager was open with them about actions which required addressing from our last inspection; this inclusive approach enabled them to work towards and sustain improvements. We observed a meeting between managers and nurses; all attendees participated and had an opportunity to speak to each agenda point. Staff commented on the leadership and said, “Yes I feel they know their stuff.” And, “[Registered manager] is approachable and supportive, and I feel confident raising concerns, seeking guidance, or requesting support when needed. They are responsive to staff feedback and is committed to continuous improvement, learning from incidents, and maintaining high standards of care.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff were able to speak up if they had concerns and had a clear policy to follow. Staff received regular supervisions and was able to approach the registered manager outside of planned supervisions and meetings. The provider spent time in the home to ensure staff could speak directly with them if needed. Staff had their own suggestion box should they wish to provide feedback anonymously. A staff member commented, “I am confident in whistleblowing procedures and would not hesitate to use them.”

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. Diversity in the workplace was respected, for example, staff had space should they wish to practice their faith. Staff’s home life commitments were considered when planning the rota to allow a healthy work/life balance for staff. Staff told us they were valued and supported; some comments included, “If we have anything private or if we don’t want to talk at the meeting we can go and talk with [registered manager].” And, “Management is supportive, my working pattern suits my needs, and I feel comfortable requesting adjustments when required.”

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. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. Improvements to overall governance had been made at the service. Audits had been re-designed to identify any inconsistencies or omissions in care records and ensure professional advice had been updated. Care plans and daily notes now reflected the support people received. Checklists had been introduced to monitor bedrail safety and the accessibility and conditions of call bells. Processes were now in place to ensure all incidents and accidents were reviewed, outcomes were analysed and where needed referrals were made to relevant professionals. Other audits remained in place and were effective in identifying areas in need of improvement, action plans were developed following these checks and stipulated a timeframe for completion and by whom. The registered manager had collated audits by month to follow up on progress made. The registered manager told us of their contingency plan and gave an example of how the plan had worked well following a local water outage.

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. Community engagement included external entertainment, visits from therapy animals, barbeques and celebrations. A recent party was held to acknowledge dignity day, relatives and people from the community attended to support their understanding of dignity in care homes. Partnership working with health and social care professionals was evident. Professionals gave positive feedback about the service. Comments included, “I have found the staff team to be engaged and receptive to advice provided. They have consistently followed guidance, communicated in a timely manner, and demonstrated safe and effective care in their practice.” And, “I have no problem with this nursing home, they [staff] are responsive and caring. When I go in there I have positive thoughts about them. Any concerns they are responsive and quickly report back and inform us of anything.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system. The registered manager and their team had made improvements to the service following our last inspection. The service received additional support from the local authority and had proactively engaged with an external consultant to further improve. The registered manager described working with local care homes to share knowledge and training. They told us they and other care home managers within the provider’s portfolio visited each other’s services to undertake audits and provide mutual support. The registered manager told us they were keen to expand on ‘champion roles’ for staff as suggested by the local authority quality team, this would involve additional learning for staff to take ownership of areas within the service.