Acacia Court

Updated 14 December 2022

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 Health and Social Care Act 2008.

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

Four inspectors and 1 Expert by Experience carried out this inspection.

An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Acacia Court is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Acacia Court is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was not a registered manager in post. However, the home manager in post was in the process of applying for registration.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 20 October 2022 and ended on 08 November 2022. We visited the location’s service on 20 October 2022.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority, local safeguarding team and Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used all of this information to plan our inspection. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.

We used all this information to plan our inspection.

During the inspection

We reviewed a range of records. This included 5 people's care records and extracts from others. We looked at 3 staff files in relation to recruitment, training and supervision. We viewed a variety of records relating to the management of the service, including records relating to accidents, incidents and safeguarding. We also reviewed a range of policies and procedures.

We spoke with the area director, home manager, deputy manager and 4 members of care, kitchen and domestic staff. We spoke with 3 people who used the service and 11 relatives, to better understand their experience of care provided at the service.

Updated 14 December 2022

About the service

Acacia Court is a residential care home providing personal care to up to 41 people. The service provides support to people aged over 65. At the time of our inspection there were 27 people using the service.

People’s experience of using this service and what we found

People's needs were assessed before they moved to Acacia Court. The provider worked together with healthcare professionals to ensure people's needs could be met. People were supported with nutrition and hydration. Staff were supported with training and supervision. However it was not always clear how training was being embedded in some areas of people's care, such as safeguarding. For example, some staff were unclear who to report to safeguarding concerns to at the local authority. We have made a recommendation about reviewing staff training and competencies.

People were safeguarded from the risk of harm and abuse and some staff understood their responsibility to keep people safe. During the inspection we raised a safeguarding alert following concerns raised by a relative. The provide took immediate action to investigate and address concerns. Medicines were managed safely. It was noted that at the time of inspection, the provider was moving to an electronic system of medication administration. People had regular risk assessments to protect them from potential harm. People were protected from the risks associated from the spread of infection. Staff were recruited safely.

People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible; policies and systems were in place that supported this practice. We observed how care staff, kitchen staff and the activities coordinator worked together to ensure a choice-based dining experience.

Staff demonstrated they knew people well and understood the way people wanted to be cared for. Staff obtained people's consent before delivering care. Some relatives told us they were not always able to express their views about care that was provided. People's privacy, dignity and independence were promoted. Staff understood how to provide personalised care. We observed a number of person centred approaches to care, such as, ensuring the volume of the television was consensually agreed by people present.

Care plans and records were personalised and contained information about people's preferred method of communication. People and relatives knew how to complain, and the provider had a system to record concerns. We saw evidence that the provider responded to concerns and complaints and lessons learnt were used to improve the service. At the time of inspection, the area director and home manager responded constructively to concerns we raised on behalf of a relative.

Relatives generally, and staff mostly, spoke positively about the management of the service. However, it was noted that the recent period of transition of management had been challenging for some relatives and staff. Managers understood their roles and responsibilities. The provider had a system to obtain feedback from people and to audit the quality of the service in order to make improvements. The area director told us how this would be built upon over the coming months.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service under the previous provider was good published 01 March 2019.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.