We visited the service on 15, 16 and 17 September 2014. We spoke with 10 members of staff, the area manager and regional manager, 11 people using the service and eight relatives. The registered manager was not on site when we inspected the service. We looked at the care records of 13 people using the service and also looked at other records relating to the running of the service such as audits, staff files and complaints records. We also spoke with two visiting professionals.The inspection team who carried out this inspection consisted of three inspectors. The inspection was unannounced, which meant the provider did not know we would be visiting.
During the inspection, the team worked together to answer five key questions; is the service safe, effective, caring, responsive and well-led?
Due to the complex needs of some people living at Acer Court Care Home they were unable to talk with us. We therefore used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. We used this to observe people in the lounge. We also carried out observations in other lounges in the service and observed lunch being served in all three dining rooms.
Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people who used the service, their relatives and the staff told us.
If you want to see the evidence that supports our summary please read the full report.
Safe
The service was not consistently safe.
People told us they felt safe and secure and we found staff had knowledge of when and how they should report any concerns about the safety of people using the service.
However, we found that some concerns and incidents had not been properly investigated by the registered manager and had not been shared with the local authority for consideration under their safeguarding adult's procedures. We found that where allegations against staff had been made, steps had not been taken to monitor and improve staff care practices. We also found a lack of systems in place to protect people from harm from other people using the service who had a history of aggressive behaviour. This meant action had not been taken to protect people from abuse or the risk of abuse.
We gave the information of five people who used the service to the local authority during our inspection. This was because we did not feel their care had been managed safely.
People consistently told us there were not enough staff on duty in the home and our observations supported what they told us.
Effective
The service was not consistently effective.
We found that although staff were given training, there were some staff whose training had lapsed. We found there were gaps in training in relation to supporting people with complex needs related to dementia.
People all had an individual care plan which was designed to set out their care needs. However, we found the plans did not always inform staff of people's current needs and abilities. This meant that people could not be sure that their individual care needs and wishes were known and planned for.
We saw that some people who had lost weight had not been referred to a dietician. This meant people were not always protected against the risks of inadequate hydration and nutrition.
Caring
The service was not consistently caring.
We saw that some staff showed patience and gave encouragement when supporting people. We received positive comments from people who were more independent. One person said, 'I am very happy here. I feel well cared for.' We observed staff interacting with people and we saw they were kind and respectful to them.
However, we found evidence that some people had not always been treated kindly and compassionately. We carried out this inspection in response to concerns raised regarding the care provided by some staff to a person who used the service. The investigation into these concerns was ongoing at the time of our visit. We are currently working with other agencies to investigate alleged poor care practice within the home.
Responsive
The service was not consistently responsive to people's needs.
Although people commented positively on the care they were given by staff, people's health needs were not always monitored and responded to appropriately.
When complaints had been raised, we saw these had been investigated and responded to. However records did not show whether people raising the complaints were happy with the response. Where there were trends in complaints, there was no analysis or learning from these to try and avoid further complaints of this nature.
Well led
The service was not consistently well led.
We found concerns in relation to the care and support people who used the service were receiving. Throughout our inspection it was clear that systems were not robust enough to ensure people received a service that provided consistent good quality care.
The home did not have effective systems to assure the quality of the service they provided. The way the service was run had been regularly reviewed but action had not always been taken to improve the service or put right any shortfalls found. Information from the analysis of accidents and incidents had not been effective in identifying changes and improvements to minimise the risk of them happening again.
We found that the service was not learning from experience because there was a lack of oversight when analysing or evaluating events to establish cause; identify any trends or themes and continually review practice. Whilst in some cases investigations were being, or had been, undertaken in relation to the conduct of some staff, there was no system in place to develop solutions and risk reduction actions to protect people and ensure future lapses were minimised.