Archived: Acacia Court

Updated 9 January 2021

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

As part of CQC’s response to care homes with outbreaks of coronavirus, we are conducting reviews to ensure that the Infection Prevention and Control practice was safe and the service was compliant with IPC measures. This was a targeted inspection looking at the infection control and prevention measures the provider has in place.

This inspection took place on 14 and 17 December 2020 and was unannounced.

Updated 9 January 2021

Acacia Court 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 Court provides personal care and accommodation for up to 27 people, many living with dementia.

There were 27 people in residence at the time of the inspection.

The home was last inspected in March 2018 and was rated ‘Requires improvement’. The inspection had been a ‘focused’ inspection which looked at a previous breach of regulations concerning safe management of medicines. We found the provider still required further improvements and remained in breach as medicine processes were still not being safely followed. We found a further breach of regulations as we were concerned that appropriate person-centred care was not always being provided; some people living with dementia were not being suitably supported.

On this inspection we found standards and improvements had been made in both areas and the service was now meeting the regulations of the Health and Social Care Act 2008 [HSCA]. We have rated the service as Good.

At the last inspection we found the environment needed to be more stimulating for the people who were living with dementia. On this inspection we found that some improvements had been made, such as easier access to the garden via an external lift, more signage and more easily accessible information on display to help orientate people living with dementia. There was more homely arrangements of furniture to aid social interaction and help people to be more comfortable in their living environment. We found there could be further improvements and we discussed these.

We saw written care plans were formulated and reviewed regularly. We saw that people and their relatives were involved in the care planning and reviews were held. This evidenced individualised care for people.

We found the failings regarding medication administration had been addressed. We now found medicines were administered safely. Medication administration records (MARs) were clear and met best practice. People received their medicines consistently.

A registered manager was in place. 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.

We found management and overall governance was stable. The registered manager was a consistent and positive lead in the home and had been effective in building a positive staff team and ensuring a consistent approach to care.

Staffing numbers ensured people’s care needs were consistently met. Feedback from staff, people using the service and visitors was positive in that staffing levels were consistently maintained to ensure safe standards of care.

People’s nutritional intake was supported appropriately. Meal times were seen to be a relaxed and enjoyable experience for people. People’s nutritional state was very well monitored.

Staff told us there were good systems in place to support them in their work such as training and supervision.

Observations and feedback from people and their relatives evidenced people’s dignity was protected and maintained.

Staff were motivated to provide meaningful activities and a consistent programme of social activities continued to be developed. These included external entertainers and therapists on a regular basis.

People’s risks regarding their health care were being adequately assessed and monitored. There was good referral and liaison with community health care professionals who worked with the home to help ensure people’s health care needs were met. The feedback we received from visiting professionals was positive.

We looked at how staff were recruited and the processes to ensure staff were suitable to work in the home. We saw checks had been made so that staff employed were suitable to work with vulnerable people.

The staff we spoke with described how they would recognise abuse and the action they would take to ensure actual or potential harm was reported. All the staff we spoke with were clear about the need to report any concerns they had.

Staff sought consent from people before providing support. When people were unable to consent, the principles of the Mental Capacity Act 2005 were followed in that an assessment of the person’s mental capacity was made and decisions made in the person’s best interest.

There were people being supported on a Deprivation of Liberty [DoLS] authorisation. DoLS is part of the Mental Capacity Act (2005) and aims to ensure people in care homes and hospitals are looked after in a way that does not inappropriately restrict their freedom unless it is in their best interests. We found these were being monitored by the registered manager of the home.

We observed staff interacting with the people they supported. We saw how staff communicated and supported people. People we spoke with and their relatives told us that staff had the skills and approach needed to ensure people were receiving the right care.

A complaints procedure was in place and people, including relatives, we spoke with were aware of how they could complain. There were records of complaints made and the provider or registered manager had provided a response to these.

The management structure within the home was clear and supported the home with clear Iines of accountability and responsibility.

There were systems in place to get feedback from people so that the service could be developed with respect to their needs and wishes.

The registered manager was aware of their responsibility to notify us [CQC] of any notifiable incidents in the home.