Acer Mews

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.

This is the first assessment for this newly registered service. This key question has been rated 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.

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 not always had a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They had not always understood the challenges and the needs of people and their communities.

People felt the new registered manager was making good progress in developing and embedding a shared direction. One staff member commented, “Information is shared to ensure we know about anything new.” However there had been several changes at management level since the home was first registered and the registered manager needed more time to embed changes made to improve the culture of the home.

Previous leaders did not always embody the culture and values of their workforce and organisation. Previous leaders had not always had the skills, knowledge, experience and credibility to lead effectively.

People and families had noted significant improvements since the registered manager had joined the service. One relative commented, “[Registered manager] is a lot better than the last manager. So much easier to approach. They will get things done. They sorted all the training after an incident and I have a lot more confidence in them.” Another relative commented on the new manager’s responsiveness telling us, “[Family member’s] food and fluids also weren’t being properly recorded but we told [registered manager] and they had a meeting with the staff about it so it has been looked at.” However, another relative commented, “Things have improved but sometimes messages don’t get passed on.” Staff spoke positively about the registered manager with one staff member telling us, “I feel well supported and I know I can raise concerns.”

We found further work was needed to ensure processes became fully embedded within the home.

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

People, relatives and staff all told us they felt able to raise concerns and felt that appropriate action would be taken. One person told us, “[Registered manager] is alright. I’d feel comfortable talking to them if I needed to.”

The provider had suitable policies and systems in place to support this and there was evidence that concerns were listened and responded to. A member of staff told us, “The manager has an open door policy and I feel confident things will be addressed.”

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 registered manager was committed to ensure a culture which prioritised equality, diversity and inclusion was being embedded within the service. Staff consistently gave positive feedback about the support they received from the registered manager and provider.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Systems for governance were in place and being used by the registered manager and the management team. The registered manager had identified many of the concerns we identified at this inspection and had already been working to address these, for example in relation to the management of medicines and further development of care plans and records. However, at the time of the inspection further work was needed to address areas of shortfalls and ensure good practice became embedded in the service to ensure people received safe and effective care.

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.

People and families generally spoke positively about how the service worked in partnership with them and other services. One relative commented, “The [registered manager] is a good manager. They arranged for [family member] to go to [a relatives] wedding which was lovely. [Family member] sees the doctor, dentist and chiropodist so they do look after them.” A health care professional commented, “There has definitely been some noted improvements identified with the new manager very open and transparent which has provided some assurances for us.”

A staff member told us about how they worked with the community and said, “When the service was first open, we did a lot of work around community mapping, so we know what services and groups are available locally. We try to take people into the community as much as we can.”

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

People and relatives told us they felt the registered manager was driving improvements. One relative commented, “Things are changing for the better. [registered manager] is great and will discuss any ideas.” A staff member told us, “[registered manager] is a good manager and is approachable. They will problem solve and will address any issues. [Registered manager] will step in to help if this is needed.”