Background to this inspection
Updated
12 January 2023
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
The inspection team consisted of an inspector and an Expert by Experience. 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 Lodge 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 Lodge is a care home with residential care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Registered Manager
This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. At the time of our inspection there was a registered manager in post.
Notice of inspection
This inspection was unannounced. We visited the location’s service on 19 and 25 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 and professionals who work with the service. The provider had completed a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.
During the inspection
We spoke with the registered manager and regional manager, the deputy manager, 2 senior carers, 3 care workers, a head housekeeper, maintenance, administrator and a member of the catering team.
We also spoke with 9 people living at the home, 5 relatives and a visiting health professional. We reviewed 4 care files in full plus other care records; 4 staff files; supervision records and a variety of records relating to the management of the service. These included electronic medication records, meetings, audits, policies, procedures and health and safety records.
After the inspection
We continued to seek clarification from the provider to validate evidence found and looked at supporting documents supplied both manually and electronically.
Updated
12 January 2023
About the service
Acacia Lodge is a residential care home providing care and accommodation for up to 60 people. The home provides care over 3 floors, with 1 floor specialising in caring for people living with dementia. The home is in the New Moston area of Manchester and is close to local amenities. There were 58 people living at the home when we inspected.
People’s experience of using this service and what we found
Risks to people's health, safety and wellbeing had been assessed and staff understood how to help keep people safe. Medicines were managed and administered safely, with regular checks completed. We were assured the measures taken by the staff team contributed towards the prevention and control of infections.
People told us they felt safe in the home and with the staff who supported them. Premises checks and all maintenance records were up to date. Required test and safety certificates were in place.
When accidents or incidents occurred, learning was identified to reduce the risk of them happening again.
The registered manager monitored staff deployment and ensured enough staff were always on duty. Processes in place ensured safe staff recruitment, with a range pre-employment checks completed. Risk assessments in relation to prospective new staff needed to be more robust.
Staff responded promptly and were attentive to people's needs. Care provided was personalised and supported people's preferences and wishes. People were supported by caring, friendly staff who knew their needs well. People told us staff were very kind and respectful.
People, their relatives, professionals and staff spoke positively about the management of the service. They had confidence in the leadership of the home. A range of audits and checks were completed to maintain and where required, implement any required improvements. The registered manager was keen to re-establish good working partnerships with professionals and local community groups following the COVID-19 pandemic, for the benefit of people living at the home.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
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 was outstanding (published 23 September 2019).
Why we inspected
The inspection was prompted in part by notification of an incident following which a person using the service died. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk in relation to the use of equipment. This inspection examined those risks.
We found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe sections of this full report.
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.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from outstanding to good based on the findings of this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Acacia Lodge on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.