Little Acre 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 this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

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 not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

A vision statement was in place; however, it was not dated and it was not clear that it had been developed through collaboration with people and staff. The provider said, “It is shared in the induction plan and handbooks along with policy and procedure.” Policies and procedures were in place but they were not dated, or version controlled and showed no evidence of review.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

Staff told us the provider, who was also the registered manager and nominated individual, had not attended the home frequently until recently, when the home manager had left. The provider did not have full knowledge of the issues and priorities for the quality of the service provided, as audits had not always identified shortfalls.

Whilst the provider was aware of their responsibilities and accountabilities as the registered manager and nominated individual, they had not maintained robust oversight of the outcome of audits. The home’s administrator had a good knowledge of systems and processes used at the home, and the provider relied on this knowledge.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

A staff member said, “We just speak up, managers are supportive.” Where concerns had been raised, they had been investigated in a timely manner and the person raising the concern spoken with. Learning from concerns had been shared in team meetings and included discussions in relation to how behaviour and actions could be interpreted by others, and how to communicate effectively.

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 was a diverse staff team, with a range of skills. Staff were positive about the home, and everyone’s diverse knowledge and experience was valued and appreciated.

The provider did not always have clear responsibilities, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

At the last inspection we recommended the provider improved their governance system to include a review of records and actions taken to ensure completeness and sustainability. A range of audits had been completed by the previous home manager, including a monthly provider/manager audit. The shortfalls noted during this assessment in relation to care plans, capacity and consent and Lasting Power of Attorney had not been identified by the provider.

There was little evidence the provider had robust oversight of the quality of the service. The provider, who is also the registered manager and nominated individual, acknowledged the need for them to have more oversight. They said, “Going forward, I will make sure all audits are properly signed. All audit findings were captured in the monthly manager’s reports that (home manger) sent me after each audit, and those findings were incorporated into the audit action plan, which (administrator) and I then followed up on.” An overarching action plan was in place, but entries were not dated, so we could not be assured action was being taken in a timely manner.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

They shared information with partners and collaborated for improvement. The provider was supportive of our assessment and responsive to our feedback commenting they would take it on board and make improvements.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people.

Quality assurance processes were not always robust and had not always focused on improving the experience of people living at the home.