Acacia Lodge 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

At the last inspection, the provider was in breach of regulation 17 Good governance. At this assessment, the provider had made enough improvements and was no longer in breach of this regulation. There were improved oversight systems and processes to monitor all aspects of the quality of care and safety within the care home. Policies, procedures and staff training in place helped to ensure people received care and support in the way they wanted. Management welcomed feedback and concerns were acted on. Management and staff were compassionate and committed to the shared visions and values. There was an open, inclusive and fair culture to improving equality and equity for staff and promoting people’s diverse needs and preferences.

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 vision and strategy to provide good quality care. They had identified areas for improvement and involved staff in the process of implementing change.

There were processes to measure the quality and effectiveness of people's care, these were used to make the changes required to continually improve staff practice and people's safety.

The provider understood the importance and how to deliver safe care. They ensured staff followed procedures designed to provide safe care, and took action where staff required re-training or disciplinary action. Staff said they felt listened to and supported, knowing the provider would take action where there were concerns. Staff said they found the provider and managers approachable and felt supported to carry out their roles by compassionate managers and leaders.

The provider had systems to measure the safety and effectiveness of people's care. They shared information with staff to enable them to understand and be involved in improving people's care.

Staff told us they felt empowered to speak up about any concerns, or to suggest ideas to improve the quality and safety of care. For example, staff had suggested a change in the deployment of staff which had been successfully adopted by the provider. This had improved the level of care people received.

The provider and managers provided a culture whereby staff had opportunity and were encouraged to speak up about poor care, or any issues relating to the smooth running of the home.

The diverse workforce were treated fairly and had opportunities to work flexibly to meet their cultural needs.

The provider ensured all staff were treated equally, taking into account their cultural needs and diversity.

Managers had oversight of people's care through monitoring of the computerised care records. Nursing staff and managers analysed the data to check people were receiving their care as planned and that staff were recording the care accurately. For example, looking at the records of what people had to eat and drink.

The provider had systems to monitor the service and use the results from this to make improvements to the quality and safety of people's care. The provider had a contingency plan in the event of an emergency and for evacuation of the home.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff were involved in the continuous learning cycle. They received feedback from audits, complaints and incidents and worked with the provider to implement the changes needed to improve the service.

The provider sought to continuously improve the service by learning from incidents, audits and feedback.