Acacia Lodge

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We assessed a number of quality statements in the Safe key question and found areas of concern. The scores for these areas have been combined with scores based on the rating from the last inspection, which was requires improvement. We identified two breaches of the legal regulations. There were arrangements in place to support people to take their medicines safely but these were not always implemented effectively. The provider had not always identified and managed risks to people's safety and wellbeing so they were supported to stay safe. There was not an established approach and strategy in place to ensure all staff were skilled and competent to meet the needs of the people using the service at all times. Staff were able to report concerns to the manager. Incidents and complaints handling was recorded, but there was no evidence this was reviewed to inform service improvements. However, there were sufficient numbers of staff to support people safely. People told us they felt safe. The provider used appropriate recruitment procedures to employ suitable staff. The service supported people to be safe from abuse.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The manager was aware of their Duty of Candour responsibilities to be supportive, open and transparent with people and relatives and to apologise when things went wrong. Staff were able to report incidents and concerns to the manager and senior staff. Staff told us the manager shared information about these with them. One member of staff said, “Accidents and safeguarding are discussed with us.”

The provider had procedures in place for handling and learning from incidents and complaints. The manager maintained logs of these to monitor how they were responded to. However, there was no evidence this information was reviewed strategically to identify learning for service improvement or any trends and remedial action to mitigate the risk of these re-occurring.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People were supported by staff who were responsive to their needs and observed to support people safely. A professional told us they had observed staff treating people well and responding to people’s needs.

The staff had completed training on how to recognise and report abuse. The staff we spoke with knew how to do this. The manager understood how to respond to allegations of abuse and neglect.

The manager reported safeguarding concerns to the local authority and CQC. The manager had set up a system for recording and monitoring safeguarding concerns to help ensure these were responded to appropriately.

Most people told us they felt safe. A person told us, “I feel happy, safe and supported, people are friendly.” Relatives’ comments included, “The hygiene of the place is good.” “It is always clean even though it is an old place” and “It is clean, but it is average and adequate overall.” However, the provider had not always identified and managed risks to people's safety and wellbeing so they were supported to stay safe. The manager could not demonstrate appropriate actions were always taken when residents health and welfare declined, such as their weight. People had basic risk assessments in place that set out actions to promote their safety.

The manager described how people’s risk assessments were reviewed regularly and updated in response to changes in a person’s health. We discussed our findings with the manager who acknowledged the management of actions in response to changes in people’s health and welfare and food preparation records needed improvement. They took steps to address this after our visit.

Systems in place to manage food safety risks to people’s safety and well-being were not always implemented effectively, such as consistent recording of what food was prepared and at what temperatures. There were fire safety arrangements in place. When we visited there was a file available with people’s evacuation plans in it, but some were not relevant to current residents. The manager corrected this after we visited. The manager completed monthly audits to check that there were safe working arrangements in place but these had not picked up and addressed the issues we found.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

There were sufficient numbers of staff to support people safely. We received mixed feedback from people about the level of staffing. Some people and relatives told us there were enough staff on shift to support them, others said they would like more staff to support them to go out more. Most people and relatives felt staff were sufficiently trained and competent to support them. One person told us, “Staff are trained well to look after me, they try their best.”

Staff told us they found training helpful to their roles. We discussed concerns around the strategic approach to staff training with the manager who acknowledged this needed to improve. Staff felt there were enough of them and told us, “We always have plenty of staff.”

Staff completed some online and face to face training sessions. However, the provider was not able to demonstrate there was an established approach and strategy to determining what mandatory and additional training staff were required to complete and when. For example, training to support people living with mental health issues or physical health conditions. This meant there weren’t processes in place to ensure all staff were skilled and competent to meet the needs of the people using the service at all times. The manager arranged for additional staff to work when required, such as when staff supported a person to a health appointment. Staff received regular supervision and felt supported by the manager and the provider. They could get advice and support when they needed to. The provider used appropriate recruitment procedures to employ staff.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

Most people and relatives we spoke with said they did not have concerns regarding the support people received with medicines. However, the management of people’s medicines support was not always safe.

We requested the provider complete an immediate audit of medicines stocks and medicines administration records (MARs) to provide assurance that people were receiving medicines as prescribed. The manager completed this and found improvements were required. Members of staff completed medicines support awareness training and manager assessed their competency to provide this support safely.

There were systems in place to support people to take their medicines, but these were not always implemented effectively. This meant people were at risk of harm from not safely receiving their medicines as prescribed. Staff used medicines administration records to note when they supported a person to take their prescribed medicines. These records did not always correspond with the number of medicines the service held for people. We found the provider had not maintained appropriate systems for checking and accounting for how many prescribed medicines the service held in stock. We raised these issues with the managers so they could address them.