Acomb Court

Updated 7 January 2021

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was undertaken by one inspector.

Service and service type

Acomb Court is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

We gave a short period of notice on the morning of the inspection to ascertain the current status of the home in relation to any Covid-19 infections and to ensure the inspection could go ahead safely.

What we did before the inspection

We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. We sought feedback from the local authority and other professionals who work with the service. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We spoke with three people who used the service about their experience of the care provided. We spoke with six members of staff including, the deputy manager, a deputy manager who was supporting the service whilst the registered manager was on leave, the provider’s quality director, a care worker and a member of the domestic team.

We reviewed a range of records. This included one person’s care records and electronic medicine records. We looked at four staff files in relation to recruitment. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training data and other records.

Updated 7 January 2021

Acomb Court provides residential and nursing care for up to 76 older persons, some of whom are living with dementia. At the time of our inspection there were 75 people living in the home.

This inspection took place on 26 and 28 July 2017 and was unannounced. The last inspection we carried out at this service was in November 2015 when we found the provider was meeting all of the regulations that we inspected and we rated the service as good.

A new registered manager was in post and the service had been taken over by a new care provider. We were told that communication about the transition to the new provider had been good. Our records showed the new manager had been formally registered with the Care Quality Commission (CQC) since June 2017. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We checked the management of medicines and found safe procedures were in place for the ordering, receipt, storage and administration of medicines. Staff received regular training and competency checks to administer medicines.

The premises were clean and well maintained. Procedures to prevent the spread of infection were followed and a number of checks to the safety of the premises and equipment were carried out. Individual risks to people were assessed and plans were in place to mitigate these. Accidents and incidents were monitored by the registered manager to check for patterns or trends.

There were suitable numbers of staff on duty during the inspection and staff records we checked found recruitment processes helped to protect people from abuse as appropriate checks on applicants were carried out. Staff had received training in the safeguarding of vulnerable adults and knew how to report concerns of a safeguarding nature.

People were generally supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. We found one example of where people’s rights and choices had not been supported due to the understanding of staff and training was provided to address this issue. We made a recommendation that the registered manager monitors practice in this area to ensure training is embedded in practice.

Staff received regular training, supervision and appraisals, and new staff completed an induction into the service.

The nutritional needs of people were supported. Assessments were carried out and action taken in the event of people at risk of malnutrition. People had access to a range of health professionals including GP, dietitian, and other healthcare professionals as required.

Staff were polite and caring towards people. We received positive feedback about the manner of staff from people, relatives and visiting professionals.

Care plans were in the process of being transferred to the standard documentation of the new provider. We found some care plans lacked detail and these were mainly the older style records. The registered manager had recognised this issue and had developed a plan to ensure all care plans were reviewed and updated while being transferred to new documentation. The newer style plans we read contained satisfactory information.

There were mixed views about the availability and suitability of activities. Some people told us they were happy with the activities available while others felt they had reduced. The activities coordinator was absent at the time of the inspection and we received confirmation that activities staff were back on duty following our inspection. We have made a recommendation that the provider monitors satisfaction with activities in light of the mixed feedback we received.

The registered manager carried out a range of meetings, audits and checks to monitor the quality and safety of the service. Staff were recognised for 'going above and beyond' and some had received 'Kindness Awards' from the company in recognition of their efforts.