Four Acres

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. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 68 (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 not successfully develop a strategy and culture which consistently promoted trust and understanding between them and the people using the service and focused on learning and improvement.

There had been 6 changes of managers at the home since our last comprehensive inspection. As a result, some staff had not received consistent support to reflect on and develop their practice when caring for people. We saw staff did not always take a proactive approach to supporting people to achieve the best possible outcomes. For example, we saw opportunities to promote and maintain people's independence and choice during mealtimes were not always maximised. This was echoed by some people who ate in their rooms. Information we received from the public and commissioners prior to this inspection highlighted concerns around care delivery, management oversight and infection control practices. Whilst we saw some improvements, further development was required.

However, positive changes had started to be introduced by the new leadership at the home, but this needed time to fully embed. Staff described improvements to the culture and management of the home, especially since the manager had taken up post in February 2026. One staff member said there was a renewed focus on meeting people’s needs and said, “We have a monthly staff meeting. We talk about lessons learned, food intake and the temperature outside, so we know to push fluids and encourage people to eat.” Another staff member said, “[Manager] is very understanding of people, and they say we need to give them a chance before making a harsh decision. She has the understanding we need to look at their medicines and review them; not just decide we cannot meet their needs.”

Staff we spoke with agreed the senior staff and managers were very good and took time to understand people and what outcomes they wanted to achieve. One staff member said, “They walk the floor. They know people and relatives. The manager encourages staff, relatives and people to go to her and I am supported and listened to.”

The provider had leaders who fully understood the context in which they delivered care, treatment and support. Leaders had the skills and knowledge in areas of care provision to lead the wider team effectively.

Despite previous management changes, staff were complementary about the support they received at the time of our visit. One staff member said, “I get on well with [manager’s name]. They are strict but fair.” Another staff member told us they had been welcomed into the team when they joined and told us, “It’s really good here and the management are supportive.” A further staff member said, “I have faith in [manager] if I take things to her, she does not just leave things on pending. If I take an issue to her it is dealt with.”

The manager said they had made themselves available to people, relatives and staff and they worked across day and night shifts so they could make themselves accessible to everyone. Staff told us there was a good flow of information from leaders. For example, people’s initial assessment informed staff, which helped ensure people had access to safe, effective and responsive care as soon as they came to live at the home. Staff were always told in advance about new admissions to the home so they could prepare and they were given the information they needed to know about people from their initial care plan. Daily flash meetings were used to allocate specific streams of work to staff teams. This helped to ensure people's needs were met. The manager said some of the feedback from our first inspection day, was discussed in the next flash meeting as a learning opportunity.

Processes to support people and staff to speak up were clear.

Staff told us they could raise any concerns with the manager, and they felt confident their concerns would be heard and acted upon. A common theme was management at the home had improved and the manager was approachable and supportive. Staff felt the overall service was better for people as a result. People and relatives knew who to raise any concerns to. Relatives told us they had feedback some issues and they were resolved.

The provider did value diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

There was a diverse workforce at Four Acres and staff told us they got on well with each other. The provider’s training programme covered equality and diversity and promoted inclusivity. The regional operations director told us recently at 1 of the provider’s other homes, staff had been offered additional training to support with ‘PRIDE’, ensuring the home was inclusive for everyone.

From reviewing people’s care information and speaking with staff, we discussed a learning opportunity with the manager. Some care plan language needed to be simplified or worded so staff with English as a second language became upskilled, to ensure they fully understood people’s care plans. For example, the word ‘de-escalation’ was written but the meaning was not fully understood. In practice, the staff member knew what to do so there was no real impact on people.

The provider did not always have clear responsibilities, roles, systems of accountability and good governance. They did not always act on the best information about risk, performance and outcomes.

The provider had a process of quality checks to assure themselves people received the right quality of care and support. Regular checks made sure, audits were completed and the manager was confident, they took actions to drive improvement. However, the issues we found around cleanliness had not been identified through regular infection control and daily walk around checks. Checks on daily record completion were reviewed, but we found a lack of detail being recorded by staff, especially for people on modified diets. Fire safety and water temperature checks were completed, but no one had questioned the small sample and the lack of clarity on what was actually checked for fire doors. We discussed these issues with the manager and regional operations director who agreed to consider ways they could capture this information.

Surveys, feedback, staff meetings and feedback from people and relatives helped the manager understand what was working well and what they needed to do to help drive improvement.

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 supported community relationships and people and relatives were encouraged to take part in activity sessions with the local and wider community. Visiting was encouraged and we saw people important to those living at Four Acres, visit them. Pet Therapy supported people, and the manager recognised the importance of animals to support positive outcomes. Some people were involved with planning a fete at the home which provided them with a sense of purpose and engagement. Outings and trips engaged people with the local and wider community.

The provider did focus 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.

There was learning from incidents at the home and across the provider’s other locations. The regional operations director said information from a recent inspection at 1 of the other provider’s homes had been shared wider. This was around better recording for people on modified diets and fluids, although we did see there was still room for improvement. Information was shared at daily flash meetings. This was then disseminated to other staff.

Leadership at the home demonstrated a commitment to developing their own skills further and to seek additional training opportunities. The deputy manager gave an example of learning taken post a choking incident, which meant they now encouraged people to eat in the dining rooms. This meant if people experienced a choking episode, this would be immediately detected and successfully resolved. However, they knew this needed to be balanced with people’s preferences for where they chose to eat their meals.

Highlights of this inspection and areas for improvement, were shared with leaders. Management listened to our feedback and told us our discussions helped them consider what they needed to improve upon. There was a positive attitude to feedback and to learn from it to improve people’s experiences.