Acorn Meadow

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• 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

We assessed 1 quality statement under this key question. Our rating for this key question remains good. The provider had suitable oversight and governance systems in place. They had developed a home improvement plan, which had a previous action signed off around risk assessments, however we found some ongoing issues in relation to robust recording of risk assessments/evaluations. Other actions were in progress and being monitored. Staff felt supported by the management team who were open and responsive. People and families were encouraged to give feedback about the service.

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.

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

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff felt supported and told us they worked as a team, with accessible managers. They said, “Managers are very approachable “and “They will help you in any way.” Feedback included, “Kindness and care is the main value. From feedback it feels like we all work well as a team. We all work hard together. Everyone knows they are important.” The registered manager was not always clear about certain policies/procedures when asked, however, they knew where to access information to clarify and referred to colleagues who had delegated responsibility. Overall, the management team were engaged, responsive and acted straight away on any issues identified or feedback provided. Staff were knowledgeable and were keen to tell us about developments within the home that had made a positive difference. We spoke with a visiting health professional who was complimentary about the service. They said communication was good and they were kept up to date. They felt the home had made improvements and people were well cared for.

The provider had oversight and governance systems in place. Various audits and checks were undertaken by staff and the provider. An audit schedule was in place. Peer medication audits had also been carried out as a further check. However, we noted some gaps in daily recording. There was a home improvement plan in place devised from the provider’s own audits, which had a previous action signed off around risk assessments, however we found ongoing issues in relation to robust recording of risk assessments/evaluations, as well as accident/incidents records. The area director's recent home visit had identified that supervisions were not up to date and planned. The actions required were being carried out and monitored via this process. The home was supported by a regional quality improvement team. The service was in the process of moving over from paper to electronic care records. Staff had received training for the new systems; however, managers may benefit from further support/guidance around other electronic recording systems. Overall CQC had been notified about incidents as required, however we found a recent serious injury, which managers had not notified us about, which appeared to have been an oversight. People and families were encouraged to give feedback. Family meetings had not been well attended and the registered manager was considering other ways to gather feedback such as a cheese and wine evening. The area director’s audit had highlighted that a staff survey was overdue.

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.

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