Acacia Lodge Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

At the last inspection, the provider was in breach of regulation 12 Safe care and treatment in relation to risks to people and regulation 13 Safeguarding people from abuse. At this assessment, the provider had made enough improvements and was no longer in breach of these regulations. Risks associated to people’s needs were identified and managed. People felt safe with the staff and the care provided. There were enough trained staff to meet people’s care needs safely. People lived in a clean and tidy environment. There were systems in place to ensure people accessed health care support when required. Feedback was acted on and any lessons learnt was shared with staff.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People felt safe and were supported to understand and manage any risks. A relative said, “We told [staff] there were a few situations, something to do with clothes and washing for [Name] but it’s all sorted now. [Name] is great now, actually, [Name] is never better.” We observed the new systems were designed to keep people safe and were effective.

The provider described how they continually learnt from incidents and implemented changes. For instance, additional training, supporting staff and feedback given about the changes made. Staff felt confident in contributing their ideas and opinions to the changes and their suggestions were listened to and incorporated. The management team were flexible in their approach to implementing changes, monitoring to ensure the changes were effective and met the individual needs of people.

The provider and managers recognised they were still in the ‘change cycle’ phase of implementing the new processes to improve the safety of people’s care, these were being fully embedded into practice. The systems that had been implemented were being adopted by staff and were becoming reliable. Staff told us they had been involved in the implementation of the new systems to improve care. We observed the new systems were designed to keep people safe and were effective. The provider continued learning from feedback from stakeholders, and they had been working with the local authority to make improvements.

People who had been recently admitted told us they had been assessed by the manager before they had been admitted to the home. They told us of the arrangements that had been made to ensure they could be moved safely between their bed and wheelchair, showing the equipment staff used.

Staff read people’s pre-assessments and current care plans, and demonstrated how they knew people’s current needs. A member of staff told us, “When we receive a new resident, we effectively carry out care planning, risk assessment and other vital information is collected.” Nurses reviewed people’s hospital discharge letters and any changes to care was incorporated into their care plans and shared with all staff. A nurse told us, “We receive a comprehensive handover between shifts”, and they described the changes in people’s care since readmission to the home from hospital.

The local authority have seen improvements in all areas of risk assessments, care planning, staff handover and embedding of these processes between January and March 2024. The introduction of regular meetings with staff in all key areas of the home improved the information sharing between them which has improved the reliability and safety of care being provided.

The provider had recently updated their procedures for ensuring staff had all the information about people’s needs to ensure they could provide safe care. There were regular reviews of risk assessments and care plans, including immediate reviews on admission or return to the home from hospital. Staff had information about people’s mobility and nutritional needs, and these were checked to ensure these were accurate and care was provided as planned.

People told us they felt safe. One person said, “I feel safe because carers are good to me, they make me feel safe.” People were confident to speak with staff if they had any concerns about their safety. One person told us they had complained about a member of agency staff and the manager had dealt with it straight away. People had been assessed for their mental capacity to consent to care; where required there had been best interest meetings and Deprivation of Liberty Safeguards (DoLS) applications made.

Staff had received training in safeguarding and knew how to raise concerns. Staff told us they felt empowered to raise issues with nurses and managers and knew their concerns would be taken seriously. The management team had reported safeguarding concerns to the local authority and had carried out investigations when instructed. They demonstrated how they used the learning from these investigations to improve the safety and quality of care. Managers and staff understood their responsibilities to assess people’s mental capacity to consent to care and ensured people’s DoLS conditions were adhered to.

We observed staff communicating well with nursing staff and management, raising any issues that required attention to ensure people received safe care. The nursing staff and managers were responsive and took action to ensure people received the care that met their needs.

There were systems in place to assess people’s mental capacity to consent to their care. The GP and other health professionals were involved in best interest meetings where decisions about people’s care were recorded. The managers had applied for DoLS applications and ensured any conditions were followed. There were systems to identify, report and record safeguarding concerns. Where the provider had been asked to investigate by the local authority, these investigations had been completed. There were systems in place to improve the service from learning from safeguarding incidents.

People told us they had been involved in their risk assessments and planning. One person who had recently moved into the home told us how they had a goal to be more mobile. Another person said the care staff provided their care the way they wanted them to, and this was reflected in their care plan. A person said, “I feel safe when carers helping me [to be moved] with the hoist because I am now used to it.” People felt confident staff knew how to mitigate risks. For instance, a person was supported by staff to be seated correctly prior to having their meal. The staff member assisted the person to eat their meal, and having small breaks between each mouthful to prevent any swallowing difficulties.

People who were able to communicate verbally and had the mental capacity to make decisions about their care could be involved in managing their risks. However, how people had been involved had not always been recorded, the provider had recognised this and this area for improvement was added to their action plan. Staff and managers knew people’s needs and involved them in making decisions at the point of providing care where possible.

People appeared happy with the care they received from staff. We observed staff talking with one person about the importance of keeping their sensor mats in place; to alert staff to them mobilising to help prevent falls. Where people had been living at the service for some time, their care records had little evidence of them being involved in the planning their care. The managers were currently reviewing the care plans and incorporating people’s views.

There was a system for assessing and recording risks. However, the system did not demonstrate how people had been involved in their assessments. The provider had recognised this and this area for improvement was added to their action plan.

People were protected from the risks associated with the premises including fire, water and health and safety hazards. One person said, “They have supported my family to be able to take me out sometimes in my wheelchair.” Another person told us they were happy and comfortable with their surroundings and knew how to use the call bell for assistance which they kept within reach.

The provider ensured the maintenance staff had the resources they needed to monitor and maintain the safety of the home.

The home was well maintained and free from obvious and potential hazards.

The provider had systems to monitor and maintain the safety of the home. Audits were used to check safety and any actions from these audits were carried out promptly.

People told us there were enough staff to meet their needs and promote their safety. One person said, “Staff are always around and checking on me.” A relative told us, “The whole team of carers and nurses are very friendly and professional, they help if they can in any way, we are very happy the way they support my relative.”

Staff told us they had received the training and support they needed to carry out their roles. Staff told us they had all received training recently in food safety in response to learning from incidents. Staff said there were enough staff deployed to meet people’s needs. The provider and managers listened to staff about the changes required for the safe deployment of staff and had implemented these changes successfully.

There were enough staff with the appropriate skills and knowledge deployed to meet people’s needs.

The provider used safe procedures in the recruitment of staff. The provider was recruiting additional staff. Where agency staff were used, they had received an induction and support to carry out their roles safely.

People’s rooms and clothes were clean. People had access to baths, showers and hand washing facilities. One person said, “Cleaning is very good normally. The cleaners sweep through quite often and then mop the floor in my room.”

Staff had the resources they needed to maintain a clean environment. Staff had received the training they required to adhere to good infection control practices.

The home appeared clean. Staff used personal protective equipment when carrying out personal care and washed their hands afterwards. Nursing staff were vigilant in monitoring for ill health.

The provider carried out audits to monitor the cleanliness of the home and equipment. There were procedures in place to identify and manage infectious diseases and prevent them from spreading within the home.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.