Acorn 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 requires improvement. At this assessment the rating has remained requires improvement. This meant the management and leadership was not always consistent. 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 good governance of 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 did welcome and support an open culture. However, improvements were needed to the systems in place for the oversight of the management of risk. People using the service, and their relatives were happy with the care. Staff were confident to identify poor practice and told us concerns would be acted on by management. Relatives told us staff were kind, caring and compassionate. Health and social care professionals provided positive feedback about the care and supported provided to people.

Staff and management fedback passionately about the care being delivered to people and spoke fondly of the people they were supporting. The provider responded positively to the feedback we provided and demonstrated a willingness to make the improvements needed.

The service had inclusive leaders who understood the context in which they delivered care, treatment and support. Leaders were visible within the service and led by example to their staff team, demonstrating inclusive behaviours. There was a stable management and staff team. The registered manager understood their legal responsibilities. Where areas of concern were identified, managers were open, honest and committed to making the required improvements. Staff knew their roles, responsibilities and how to support each other. Relatives and visiting professionals spoke highly of the staff and management team.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff were provided with the relevant policies and procedures detailing what was expected of staff working for the service. Staff told us they felt able to raise any issues or concerns, including poor practice. Staff were confident senior staff would listen to them. However, not all staff were clear about who they would contact externally if needed. We observed the registered manager had a calm manner and spoke to people and their relatives with kindness.

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. There were processes for staff recruitment and induction. Staff felt respected and able to work in an environment that was supportive and free from discrimination. Support and reasonable adjustments were in place for staff when needed. A staff member told us, “I feel very well supported as a staff member and I really enjoy my job.”

The provider’s governance systems were not always effective. These systems had not enabled them to address the shortfalls in risks we identified during our inspection. The oversight of risk to people was not consistently robust and the provider’s own systems had not identified this. Care records did not always give clear guidance about health conditions, ligature risks were not robustly managed, there were a number of potential hazards in the grounds, recruitment practice checks were not consistently robust, and the management of rescue medicines lacked guidance for staff.

There was a programme of internal and external audits and checks to monitor the quality of the care provided. The registered manager understood their responsibility to provide honest information, and to apply the duty of candour where appropriate. Relatives and visiting professionals spoke highly of the staff and management team.

The provider responded promptly to our inspection and took some immediate actions during and following our site visit to ensure the safety and wellbeing of people.

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. Partners had positive experiences of working with the provider to collaborate on the delivery of safe, high-quality care to people. Health and social care professionals told us staff were caring, kind, supported people well, provided them with time to explain issues and where possible did what they could to help.

The provider’s systems and processes for assessing and monitoring the safety and quality of people’s care were not always robust or effective. The provider had systems in place to monitor the service and drive improvement and action plans were in place. For example, following an incident at mealtime a lot of work had taken place to improve the mealtime experience for people. However, our inspection identified 2 breaches relating to safe care and good governance and identified safety concerns that had not been identified by the provider’s systems or had not been addressed in a timely way. The provider demonstrated throughout the inspection process they wanted to drive the improvements needed.