Acacia Lodge

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

We assessed a number of quality statements in the Well-led key question and found areas of concern. The scores for these areas have been combined with scores based on the rating from the last inspection, which was requires improvement. We identified a breach of the legal regulations. There were systems to supervise the quality of the service but these were not consistent and robust enough to demonstrate that safety and quality was always monitored, assessed and managed effectively. Staff were encouraged to speak up and raise concerns.

This service scored 50 (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.

Staff said they could raise issues to the manager. A member of staff said, “The manager is very approachable.” The manager described how they encouraged staff to report concerns.

The provider had safeguarding and whistleblowing policies and procedures in place to support and promote staff raising issues.

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 said they felt supported and spoke positively about the manager. Their comments included, “The manager is very friendly and supportive”, “Friendly but firm” and “The manager is always visible and spends time with residents.” Staff felt the manager had made some improvements since they started in the year before our visit. The manager set out their vision for clear, effective governance arrangements at the service and acknowledged these required improvement.

The quality assurance systems, such as a monthly service audit, had not enabled the provider to identify and take timely action to address areas for improvement. For example regarding people’s medicines support, care plans, safe care and treatment, meeting nutritional and hydration needs, staffing and good governance. We received mixed feedback about how improvements to the home’s environment were managed. A person’s window had recently been painted shut and another person’s access to their en suite toileting facilities had been periodically curtailed over a period of five months due to as plumbing problem. There was a verbal handover of issues affecting people and the service between staff at each shift change, but this was not recorded. A food hygiene rating poster on display was out of date. People’s daily care records were not always up to date. These issues indicated there were not always robust arrangements for maintaining records relating to people’s care and the management of the service. The manager had devised a service improvement plan in the year prior to our visit. This was based in developing a competent staff team, implementing effective compliance systems and improving care recording. However, this was not up to date or in active use when we visited and had not been effective at the time of our assessment.

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.