Acquah Lodge- 60 Dalkeith Grove

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 good. At this assessment the rating has remained good. This meant the service was consistently managed and well-led.

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 provider had a shared vision, strategy and culture that supported people to receive compassionate, person centred care for people in supported living settings.

Staff were described as skilled, consistent and understanding, particularly when supporting people with complex needs or behaviours that could be challenging. A relative told us, “My [family member] has autism and there are certain triggers for [them]. Staff seem to be aware of this. They are the experts on [my family member]. I used to be but they are now.”

The culture within the service encouraged openness. Staff told us management encouraged a positive culture of learning and development at the service. They said they felt listened too and valued. Staff were aligned with the provider’s values and were positive about working at the service. A member of staff told us, “There is an open office policy so I can easily express myself. Communication is great here.”

Staff undertook a range of training and had used this to help ensure procedures were followed to provide people with good quality care. There was regular communication between staff so that they could share their experiences and learn from one another. Systems and processes had been designed in line with the service’s vision and values and focused on people and meeting their individual needs.

The provider had inclusive leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. However, the registered manager had not always ensured their regulatory responsibilities were carried out. Providers are required to notify CQC about certain events and changes to their registration. The provider had not always done this. During this assessment, we were alerted that the registered manager had failed to notify CQC of a variation to their registration. We discussed this with the registered manager to ensure they understood the regulatory requirements and they sent the relevant notification to the CQC.

There was an organisational structure in place and staff understood their roles, responsibilities and contributions to the service. Management were responsive when things went wrong and took action to make improvements. Throughout the assessment of the service, management and staff we spoke with acted with openness and integrity.

During the site visit we observed positive interactions between people who used the service and management. People appeared familiar and comfortable in their presence. Relatives spoke positively about the management of the service. A relative said, “The manager is very responsive. I can call [the registered manager] over the weekend and [they] respond and guide me in the right direction. [They] always respond to me. I have peace of mind.”

Staff told us management were knowledgeable and provided them with the support they needed to do their job effectively. There was open and ongoing communication between the management team and staff. Staff were complimentary about the leadership approach of the registered manager who they described as approachable. A member of staff told us, “[The registered manager] is a nice person. Very easy to talk to and we have a great working relationship. [They] are the kind of person that you can go and talk to and I wouldn’t think twice to talk to [them].”

The provider fostered a positive culture where people and relatives felt they could speak up and their voice would be heard. There were clear reporting structures, staff understood who to speak up to and how.

People, relatives, and staff were encouraged to speak up, and they told us they felt able to do so. A relative told us, “[The registered manager] is very proactive.” Another relative said, “I am absolutely confident to raise concerns with [the registered manager]. We have a good working relationship and communication. They keep me informed of what is happening. When I contact them, they always respond.”

Staff told us they felt confident that they could raise any issues with the leaders, and they would be taken seriously and investigated. The provider had a whistle blowing policy in place, which detailed how staff could speak up about any concerns they had about the service. Management were regularly in contact with staff and this helped to promote an open rapport and effective working relationships.

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.

Managers were responsive to staff’s individual circumstances. This helped to ensure reasonable adjustments were made to accommodate staff’s needs.

Staff spoke positively about working at the service and said that their diversity needs were met. Staff were supported with flexible working conditions, felt discrimination would be challenged and had opportunities to celebrate their diversity.

The provider had responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support.

Systems and processes were in place to help monitor the quality and effectiveness of the service to help ensure risks were identified and mitigated, enabling and empowering people to receive good quality and safe care. Governance processes including audits and checks were carried out. Management carried out a monthly audit of each supported living service looking at areas which included care records, medication and the premises.

There was a management structure in place, with all staff being clear on their duties and responsibilities. Management had oversight of the running of 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. The provider told us they worked with other professionals to help make sure people received continuity in their care.

People’s community participation was encouraged and supported, with staff supporting people to access activities, develop independence and build relationships outside of their home.

The provider focused on continuous learning, innovation and improvement. Management looked for ways to improve the running of the service and the quality of care people received. Systems were in place to seek feedback from people, relatives and staff. People, relatives and staff were encouraged to provide feedback.

The culture within the service promoted honesty and learning from mistakes and there was a clear understanding of the need to be open in the event of anything going wrong.