Tree Vale Limited Acorn House

Prior to our visit, Wirral NHS Infection Control team had inspected the service. They were happy with standard of infection control and had no concerns.

During our visit, we found the following examples of good practice.

At the time of our visit, the home was closed to visitors due to an outbreak of Coronavirus in the home. People had been supported to maintain contact with their loved ones via video and telephone calls during the outbreak. Prior to the outbreak, excellent provisions were in place to ensure visitors to the service were safe to enter the home to see their loved ones For example, visitors were required to have a negative test on site and provided with a full set of PPE to wear prior to entry.

There were systems in place to maintain good infection control standards and regular checks were undertaken. Staff had sufficient supplies of personal protective equipment to protect them from risk and clinical waste was disposed of in accordance with government guidelines to prevent cross infection.

At the time of our visit, the home was closed to new admissions due to the outbreak. However, prior to this, all new people admitted to the home were required to have negative Covid 19 test prior to admission and a period of isolation where practicable. No new people had been admitted to the home in the last six months.

Staff members were tested weekly for Covid 19 and people living in the home monthly, in accordance with government guidelines.

Just after Christmas, a significant number of people living in the home and staff tested positive for Covid 19. During our visit, we reviewed the infection control measures in place to manage Covid 19 and the care people received. We had no concerns. The support and risks associated with this were managed well. People who had not tested positive for Covid 19 were isolating in their own bedrooms and staff were taking appropriate precautions to maintain their safety.

Staff who had tested positive were isolating at home. The provider had sourced a small number of agency staff to work in the home to ensure the service was safely staffed. They had secured assurances from the agency that the staff did not work in other homes whilst working in Tree Vale Limited Acorn House. This was important to mitigate the risk of spreading infection to and from other care homes.

The provider had alerted the local authority, the NHS infection control team, Public Health England and CQC of the outbreak. They had sought and followed any advice and support given.

Further information is in the detailed findings below.

Tree Vale Acorn House is registered to provide accommodation for up to 33 people who require accommodation and support with their personal care. The home is located in residential area. At the time of our inspection there were 28 people who lived at the home.

At the last inspection the service was rated overall requires improvement. At this inspection we found the service had continued to improve and a rating of ‘good’ has been achieved. This reflects the hard work of the manager, deputy manager, provider and staff since our last inspection.

We spoke with three people who lived in the home. They all gave spoke highly of the home and the staff who supported them. It was clear from what people said that the manager and staff team were well thought of. They told us the manager and staff were kind, caring and that the support provided was good.

People’s care records contained clear and easy to understand information about people’s needs and risks and how to support them effectively. People’s life histories were included and gave staff information about their families, life prior to coming to live at the home and the things that were important to them in their day to day lives. This gave staff an understanding of the people they supported so that positive relationships could be developed.

Staff spoken with had a good knowledge of people’s needs and spoke with genuine affection about the people they supported. The atmosphere at the home was warm, homely and relaxed. People and staff chatted socially to each other, these conversations were natural and it was obvious that people had warm relationships with staff members.

Staff recruitment was safe. The service was staffed sufficiently at all times and staff had received the training and support they needed to provide safe and appropriate care.

People’s physical emotional well-being was at the forefront of the service. Where people’s mental health had declined we saw that prompt action was taken to get people the help they needed. Where people needed help to make informed decisions about their care, the Mental Capacity Act 2005 had been followed to ensure that people had the support of external advocacy service or family members. Records showed that any decisions made on people’s behalf had been done so in their best interests.

People’s physical health was monitored and responded to quickly if they became unwell. Changes in people’s mobility needs were promptly addressed with referrals to the falls prevention team or occupational therapy for a re-assessment of their needs.

Accidents and incidents and people’s health needs were managed appropriately with support from a range of health and social care professionals. Medication was managed satisfactorily and staff had clear guidance on how and when to administer ‘as and when’ required medications such as Paracetamol in order to maintain people’s comfort.

People received enough to eat and drink and had a choice. People told us the food was of a good quality and we saw that portion sizes were ample. Where people did not like what was on offer, an alternative meal was provided without hesitation.

A range of person centred activities were provided ranging from a music sessions, nail care, balloon games, bingo and quizzes. This promoted people’s social and emotional well-being. People’s well-being and level of participation in the activities provided was monitored and responded to where appropriate.

There were a range of effective mechanisms in place to monitor the quality and safety of the service and the views of people were regularly sought by the manager. This was good practice.

During our visit, we had no concerns about people’s care or the service itself. We found the home to be well-run with a passionate and caring staff team who worked hard to provide good care.

Tree Vale Acorn House is a four storey care home situated in a residential area of Prenton, Wirral. The home provides accommodation and personal care for up to 33 older adults. The home primarily caters for adults who live with dementia. Accommodation consists of 33 single bedrooms. On the ground floor, there is a communal lounge and dining room for people to use. There is also an additional small lounge on the first floor.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission 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.’

At our last visit in November 2016, we identified multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The service was rated inadequate and placed in special measures. During this visit we followed up the breaches we identified at our previous visit and found that significant improvements had been made. These improvements meant that all of the breaches we identified in November 2016 had been addressed. At this inspection, the service was compliant with all of the health and social care regulations.

As the domains of safe, responsive and well-led were rated inadequate at our last inspection, we were unable to rate them any higher than requires improvement at this inspection. This was because the provider needs to show that they can sustain these improvements over time. We will therefore check this at our next inspection. The domains of effective and caring which were rated ‘requires improvement’ at the last inspection were found to be good at this inspection.

We looked at the care files belonging to four people. We saw that the assessment of people’s risks had improved. People’s risk management plans contained sufficient information for staff to follow to mitigate risks in the delivery of care and people’s care plans were person centred. This meant that people’s individual needs, preferences and wishes in relation to their care were clearly stated and planned for. It was obvious from looking at people’s care plans that staff knew people well and understood the people they were caring for.

We saw that where specific risks in relation to people’s care were identified, these were acted upon a timely manner to ensure people received the support they needed. For example, where people had frequent or multiple falls over a short period of time, they had been referred to the falls prevention team appropriately and assistive technology ordered to help keep them safe. People’s accident and incidents were now properly monitored to ensure information about people’s risks was used to plan safe and appropriate care..

People whose ability to make decisions was in question, had their capacity assessed. It was clear from looking at this documentation that people were involved in their own assessment. We saw that any decisions made in relation to people’s care had followed a best interest process where the person’s capacity was found to be impaired. During our visit, we saw that staff ensured people’s consent was obtained before any support was provided and that people had a choice with regards to how they lived their lives at the home.

We checked medication management. We found that medicines were now stored at appropriate temperatures. There were also systems in place to enable the manager to check and account for medication that had been administered.

People’s weights were taken and monitored regularly to ensure they maintained a health weight. Improvements had been made to people’s dining room experience. Napkins and condiments were available for people to use during mealtimes and people’s meals were now served on appropriate sized dinner plates. We saw that the menu was displayed in picture format as well as in writing. This was good practice as it helped people who lived with dementia to recognise the food choices on offer so that they could choose accordingly.

Staff were kind, caring and compassionate in their interactions with people. People were supported at their own pace and the atmosphere at the home was warm and relaxed. We observed many positive interactions between people who lived at the home and staff. People looked happy and comfortable in the company of staff and well looked after.

We saw that people had access to a range of activities. The activities co-ordinator played an active role in the home, encouraging and supporting people to participate in the activities on offer. On the day of our visit, people enjoyed painting on easels and a game of ‘play your cards right’. Staff were recruited safely and there were enough staff on duty to meet people’s practical needs as well as to sit and chat to them socially. This promoted people’s emotional well-being.

Staff received the training they needed to do their job role effectively. The provider had made improvements to the way training was provided to ensure everyone received the training they needed in a timely manner. Staff told us they felt supported in their job role and records confirmed that staff had received appropriate supervision.

The provider’s complaints policy had been reviewed. The new policy was clear and gave people the correct contact details for those organisations people could contact in the event of a complaint. It also contained the photographs of the staff people could talk to at the home should they have any concerns. This was good practice.

Improvements to the way the laundry operated had been made to ensure people’s belongings were treated with care. People’s right to privacy and dignity was maintained at all times. We saw that people’s confidential information was stored securely to protect their right to confidentiality.

The quality assurance systems in place at the home to monitor and manage risks to people’s health, safety and welfare had been reviewed. The manager, deputy manager and provider had worked hard to ensure that the systems in place were now fit for purpose. It was clear that the whole staff team had pulled together to ensure that the changes introduced by manager, deputy manager and provider were effective. This had resulted in many positive changes to the way the service was managed and delivered. As a result of this hard work, the service is no longer in special measures.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission 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.’

During this visit, we identified concerns with the safety and quality of the service. We found breaches in relation to Regulations 9, 10, 11, 12, 14, 16 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

We looked at the care files belonging to five people and found their needs and risks were not properly assessed, planned for or managed. There was insufficient information in people’s files on how to keep people safe and meet their needs in a way they preferred. Risk assessments were inadequate and did not provide staff with sufficient guidance on how to manage people’s risks in order to keep them safe. People’s health needs were not adequately described and records showed that they had not always been followed up with healthcare professionals. Dementia care planning was poor and staff had limited guidance on how to provide safe, appropriate person centred care.

We found people’s capacity was assessed using the two stage test recommended by the Mental Capacity Act 2005 but people’s assessments were generic and lacked evidence of their involvement in the assessment process. It was unclear how these assessments had been undertaken as there were no best interest decision records on file and no evidence that any least restrictive options had been explored. Some people had deprivation of liberty safeguarding (DoLS) in place but there was limited evidence as to how an assessment of their capacity in relation to this had been made.

Medicines were not always managed safely. Medicines received by the home were not always properly accounted for or stored at appropriate temperatures. This meant the management of medications was unsafe.

Systems in place to ensure people receive adequate nutrition and hydration were not robust. Risk assessments and care planning for people’s dietary needs was poor and people’s weights were not always monitored appropriately for any unintentional weight loss to be picked up and addressed. Professional advice was not properly documented and healthcare appointments were not routinely followed up to ensure the person received the nutritional support they needed.

People’s accidents and incidents were not monitored adequately to ensure action was taken to protect them from avoidable harm. A number of people had experienced multiple falls without a referral to the falls prevention team being made or assistive technology being put into place to help staff manage people’s safety. This meant that the manager had failed to take any appropriate action to keep people safe. Poor moving and handling techniques were observed in use by staff at the home. This placed people at risk of injury. We spoke with the manager and senior carer about this and asked them to address it immediately.

Staff were observed to be kind, caring and compassionate in their interactions with people. There were lots of positive interactions between care staff and the people they looked after. Care staff spoke about the people they cared for with a genuine fondness and were able to tell us about some of their needs. Senior staff were a visible presence on the floor and supervised care staff well. The senior staff member we spoke with during our visit was observed to have good relationships with the people they cared for and their families. We saw that relatives and visitors were made welcome throughout the day and they told us they felt staff were approachable and kind.

People had access to a range of activities and the home employed an activities co-ordinator specifically for this purpose. During our visit, we saw that the activities co-ordinator played an active role and encouraged people to participate in the activities on offer. We found however that the planning of people’s activities required improvement to ensure people knew what activities were on offer and that they met their preferences.

Safeguarding incidents were recorded and records showed were appropriately investigated and reported. Staff we spoke with knew about types of abuse and the action to take if they suspected abuse had occurred.

Staff recruitment was satisfactory and the majority of staff had received most of the training they needed to do their job role effectively. Some staff however did not receive their training in a timely manner. This meant they may have lacked some of the skills required for their job role. During our visit we saw that the number of staff on duty was sufficient but the majority of people were sat in the same room for the majority of the time and were not able to freely mobilise around the home. This made it easier for staff to manage people’s requests for assistance.

We looked at the way the provider handled complaints. We found evidence that the provider’s approach to people’s complaints failed to ensure their concerns were responded to appropriately.

We also saw that the manager had failed to consistently address on-going concerns expressed by relatives in respect of people’s personal belongings and that people’s belonging were not always treated with respect. Some of the language used within the home to describe people, was inappropriate and disrespectful. This did not demonstrate that the management of the service cared about things that were important to people and their families.

The service was not well –led. Systems in place to monitor and manage risk to people’s health, safety and welfare were limited and those that were in place were ineffective. There were no audits in place to check the management of people’s care, accident and incidents, medication, health and safety, cleanliness and infection control. People did not have personal evacuation plans in place to ensure they were evacuated safely in the event of a fire and there were no effective systems in place to check that the home was a safe, clean and comfortable place to live.

During our inspection, the manager was not a visible presence and spent the majority of their day in the office. From our discussions about people’s care and the service, they failed to demonstrate that they had an adequate understanding of people’s needs and care and that they had sufficient knowledge of their managerial and legal responsibilities under the health and social care act. There was also no evidence that the provider audited the service, as a legal provider of regulated care to ensure that the service was safe, effective, caring, responsive and well-led.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

- Ensure that providers found to be providing inadequate care significantly improve.

- Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

- Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

-

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action.

Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

'I wouldn't want her to be anywhere else but here.'

'She's very happy and well looked after here.'

We saw that people were supported to remain as mobile as possible and assistive technology had been introduced to help reduce the risk of falls.

We looked all around the home and it was clean, tidy and in a good state of repair and decoration.

Personnel records showed that the home's recruitment procedures were followed and the required records were in place before people started working at the home. All staff who worked in the home, including domestic assistants and kitchen staff, received the same core training. Duty rotas showed that there was a sufficient number of qualified and experienced staff employed at the home to ensure that people were kept safe and their care needs were met.

The home had a complaints procedure and a copy of this was given to people new to the home and their families. The manager kept records of any complaints received and of how the complaint had been investigated, addressed, and responded to.

All of the people we spoke with told us the food was good and that they were given choices in what they wanted to eat. One person told us 'I get plenty to eat' and another said 'the food is usually good but you can always have an alternative meal if you don't like what is on the menu.'

We saw that staff were well supported to carry out their role and received regular training. We had a minor concern at a previous inspection with regards to documentation. We found at this inspection that improvements had been made.