Acacia 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 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.

The provider was previously in breach of the legal regulation relating to good governance. Improvements were found at this assessment and the provider was no longer in breach of this regulation.

Leaders had strengthened quality assurance systems and used audits, reviews and oversight processes to monitor quality and drive improvement.
 

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.

The provider promoted a shared culture focused on continuous improvement, person-centred care and open communication. Staff were kept informed through regular team meetings, handovers and electronic communications.

We reviewed team meeting records which showed leaders discussing service improvements, people's changing needs, professional referrals, medicines management, care planning and communication processes.

This helped ensure staff understood the provider's priorities and expectations, contributing to consistent and coordinated care for people using the service.

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.

The registered manager demonstrated a detailed understanding of the service, its challenges and the needs of people using the service. They spoke openly and honestly about areas that had previously required improvement and were able to clearly explain the actions taken to address these. Throughout the assessment, the registered manager demonstrated a reflective approach and a clear vision for improving the quality of care provided. Leaders promoted continuous improvement through regular review, monitoring and oversight arrangements.

A relative told us, "The manager is good." Staff also spoke positively about the support they received from leaders. A member of staff said the registered manager was “very understanding” and supportive when they had experienced health difficulties.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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 survey responses indicated staff received equality and diversity training and felt they had the knowledge and support required to provide inclusive care. Staff were encouraged to share their views through surveys, supervision and team meetings, helping to ensure different perspectives were heard and considered. The provider reviewed feedback received and identified actions where improvements could be made, demonstrating a commitment to continuous improvement and inclusion. Staff described the workforce as diverse and inclusive. One member of staff told us, "Yeah, all the staff are from different backgrounds."

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.

The registered manager demonstrated clear understanding of previous breaches. They had implemented weekly and monthly audits with actions that were followed up. The provider had an improvement action plan which the registered manager monitored weekly. The plan contained specific goals, who was responsible, timescales and status. This supported oversight, enabled prompt action where issues were identified and strengthened governance arrangements across the service.

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.

We saw examples of joint working with a range of partner agencies and professionals. Professional advice and recommendations informed the support people received and leaders worked with partner agencies when people's needs changed. The provider maintained communication with families through meetings, newsletters and ongoing contact and worked collaboratively with professionals to help improve outcomes for people.

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. They actively contributed to safe, effective practice and research.

Leaders had implemented a range of improvements since the previous assessment, including strengthened governance systems, medicines oversight, weight monitoring processes, care planning arrangements and activities. Staff recognised improvements in oversight and governance, with a care worker telling us there are, "more oversight and audits now." We saw feedback from people, relatives and staff was reviewed and used to inform service development and identify opportunities for improvement. The provider demonstrated a commitment to learning from incidents, complaints, audits and stakeholder feedback to improve outcomes for people.