Archived: Acacia Lodge Care Home

We found the following examples of good practice.

People were supported by staff to keep in touch with those important to them. Relatives and friends visiting the home were required to complete a COVID-19 test, had their temperature check and wore personal protective equipment (PPE), which included an apron and a mask.

Staff and essential care givers engaged with a programme of regular testing according to government guidance. Staff and visiting professionals were asked to provide evidence of their vaccination status against COVID-19 prior to entering the home.

We saw PPE was accessible within the home and staff used it in accordance with the most up to date guidance. Information about the correct use of PPE and handwashing guidance was displayed throughout the home.

Staff worked in designated areas of the home. In the event of an outbreak at Acacia Lodge, staff would use a separate entrance dependent upon which area of the home they worked within. This would help reduce the potential spread of infection amongst the staff and residents.

Cleaning schedules and recording documents had been designed specifically for each area of the home and were reviewed weekly. Guidance for the management of laundry had been laminated and displayed in the laundry area.

A monthly internal infection control audit was undertaken. The outcome of the audit was entered onto the provider’s electronic recording system, and any improvements required were monitored for their progress and completion. A meeting was held with the heads of each department in the home following an audit to share the outcome and agree the actions where improvements were needed.

Acacia Lodge Care Home is a nursing home providing personal and nursing care for up to 40 people with dementia and physical disabilities. There were 22 people receiving care at the time of the inspection.

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

Records required improvement. We found gaps in the recording of peoples care needs such as, repositioning, fluid management and safety checks.

Medicine management required improvement. We found concerns relating to the information and recording of medicines.

Health and safety checks were in place however, we found records of low water temperatures which increased the risk of Legionnaires disease.

People were not always safeguarded from the risk of abuse. Unexplained bruises had not always been investigated.

The provider and registered manager lacked oversight of the service. Audits completed did not identify the issues found on inspection.

Staff told us they did not always feel supported by the registered manager.

Staffing levels required reviewing. Staff rotas showed there was not always a consistent number of staff for each shift.

People were protected against infection. Staff wore appropriate personal protective equipment [PPE] and the home appeared clean.

People, staff and relatives were encouraged to feedback on the service. The registered manager and staff supported communication between people and their families throughout the pandemic.

Staff demonstrated that they knew people well including their likes, dislikes and personal preferences.

Rating at last inspection

The last rating for this service was good (12 October 2018).

Why we inspected

We received concerns in relation to safeguarding and staffing. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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 coronavirus and other infection outbreaks effectively.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Acacia Lodge Care Home on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service.

We have identified breaches in relation to safe care and treatment and management oversight at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

This was our first inspection of the service since they registered with us.

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

Acacia Lodge Care Home can accommodate up to 40 people in one adapted building. It provides a service to older people, some of whom have nursing or dementia related care needs. At the time of this inspection, 35 people were living in the home.

Care planning and risk assessments were personalised and mentioned the specific care each person required, including their likes and dislikes. However, most of the staff we spoke with had not read people’s care plans. This meant they could not evidence they were fully informed and up to date with any changes to people’s care.

People were involved in their own care planning as much as they could be, and were able to contribute to the way in which they were supported. People told us they felt in control of their care and were listened to by staff.

The service had a registered manager. 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.

People told us they felt safe, and staff had an understanding of abuse and the safeguarding procedures that should be followed to report abuse. People had risk assessments in place to cover any risks that were present within their lives, and actions were taken to reduce risk where possible. All the staff we spoke with were confident that any concerns they raised would be followed up appropriately by the registered manager.

Staffing levels were adequate to meet people's current needs, and rotas showed that staffing was consistent.

The staff recruitment procedures ensured that appropriate pre-employment checks were carried out to ensure only suitable staff worked at the service. References and security checks were carried out as required.

Staff attended induction training where they completed mandatory training courses and were able to shadow more experienced staff giving care. Staff told us that they were able to update their mandatory training with short refresher courses.

Nursing staff supported people with the administration of medicines, and were trained to do so. The people we spoke with were happy with the support they received.

People's consent was gained before any care was provided and the requirements of the Mental Capacity Act 2005 were met. Consent forms were signed and within people’s files.

People were able to choose the food and drink they wanted and staff supported people with this, and people could be supported to access health professionals when required. All aspects of people’s health was documented within their files and updated regularly.

Staff treated people with kindness, dignity and respect and spent time getting to know them and their specific needs and wishes. People told us they were happy with the way that staff spoke to them, and provided their care in a respectful and dignified manner.

The service had a complaints procedure in place to ensure that people and their families were able to provide feedback about their care and to help the service make improvements where required.

The people we spoke with knew how to use it.

Quality monitoring systems and processes were in place and comprehensive audits were taking place within the service to identify where improvements could be made.

The service worked in partnership with other agencies to ensure quality of care across all levels. Communication was open and honest, and improvements were highlighted and worked upon as required.