Acton Care Centre

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 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 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service 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 registered manager and staff actively sought the views of people and their families through meetings and surveys.

The staff spoke positively about their experience working at the service. They told us they would recommend it as a place to work and a place for a loved one to be cared for.

We observed staff being warm and friendly to people and they seemed to work well as a team.

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 were positive about the support provided by the management team. Comments from staff included “Definitely, a strong team from top management, leadership down to junior staff. I feel I am being supported, what I have is beyond my expectations.” Another comment “I like the system they understand the life of staff.”

The provider fostered a positive and open culture where people felt their voices were heard. Staff told us they felt confident speaking up and described managers as approachable and receptive to feedback.

The provider had a variety of formats in place to collect people’s views throughout the year; this included meetings with people and relatives, staff meetings and surveys.

Relatives told us they felt comfortable to speak to the management team and the nurses if they needed too. Relatives commented “I can always speak to the manager or the Head Nurse if I need to, I have had no issues at all really” another relative said “I can speak to the manager if I want, they let me know if [relative] is unwell or is going to Hospital”.

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 provider had policies and procedures supporting diversity and inclusion within the service in place and promoted diversity and inclusion in the workforce.

Staff spoke positively about working for the service. A member of staff had been employed there for 22 years, reflecting a level of stability and commitment within the team.

The provider’s systems did not always ensure good governance, but they had clear responsibilities, roles and systems of accountability and used these to manage and deliver good quality, sustainable care, treatment and support. They acted on information about risk, performance and outcomes.

The provider’s quality assurance systems for medicines were not robust and had failed to identify the concerns found during this inspection in relation to medicines.

Following on from our inspection the provider sent assurances that concerns we had, had been dealt with accordingly including the audit process.

Audits for other areas were robust, and any areas of concern were acted upon.

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 provider worked closely with various external agencies including, GPs and the Local Authority.

Relatives, staff, and the registered manager shared positive examples of collaborative working in partnership. These included success stories where people had been supported to improve their health or health outcomes.

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.

The provider had a shared learning tool in place documenting identified areas for improvement, from incidents, accidents and complaints which was distributed between the provider’s care homes with recommendations and actions to be completed. There was clear evidence feedback from both staff and people had been listened to and acted upon, showing a commitment to learning and service development. Staff were encouraged to complete feedback forms, which helped the provider understand their views and identify areas for learning and development. Meetings with people were held monthly and these were recorded. Discussion points included menus and food quality and choice, complaints and grumbles, confidentiality and abuse.

The management team was focused on learning and improvement. They were responsive to feedback given on the day of inspection and acted on it immediately. Learning was shared across the provider’s homes at regular manager meetings.