Acacia Court

Updated 2 February 2024

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 was carried out by 2 inspectors on the first day and 1 inspector on the second day.

Service and service type

Acacia court 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 Court is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was not a registered manager in post. However, the manager had submitted their application to register with CQC.

Notice of inspection

This inspection was unannounced.

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. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 9 members of staff including the manager, regional manager, senior care staff, care staff and the chef. We spoke with 2 people and 3 relatives about their experiences of the care provided. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We reviewed a range of records including 5 people's care records, multiple medication administration records, and 3 staff personnel files in relation to recruitment. We also reviewed a variety of records relating to the management and governance of the service.

We reviewed evidence that was sent to us remotely as well as seeking clarification from the provider and manager to validate evidence found. We looked at audit and governance data, as well as policies and procedures.

Updated 2 February 2024

About the service

Acacia Court is a residential care home located in Southport. The home provides accommodation for up to 27 people across three floors. People have access to a communal lounge, dining area and a spacious garden. The service provides support to older people including people living with dementia. At the time of our inspection there were 24 people using the service.

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

There were systems in place to monitor the quality and safety of the service. However, some missing information in people’s care records and lack of detailed protocols for ‘as and when required’ medicines had not been identified by the provider. Overall, we were assured medicines were safely managed.

Individual incidents were reviewed and action was taken to reduce the risk of recurrence. However, the manager did not always robustly analyse overall themes and trends to identify additional opportunities to improve safety. We have made a recommendation about this.

The environment was not fully designed to meet the needs of people living with dementia. However, a recent survey had been conducted by an external agency who specialise in environmental design for people living with dementia and an action plan was underway to make the necessary improvements. The communal areas of the home and people's bedrooms were clean and hygienic.

At the time of the inspection, no structured activities plan was in place. However, our observations found people were generally engaged. Before the end of the inspection, a full activity plan was put in place which was designed to offer meaningful stimulation and meet people’s social needs.

Risks to people’s health and safety were assessed and measures were in place to mitigate the risk. Staff knew people’s individual risks and followed control measures needed to keep people safe. Staff were knowledgeable about people's dietary needs and supported them to maintain adequate nutrition and hydration levels.

People were protected from abuse. Staff received appropriate training and were clear on the potential signs of abuse and how to raise concerns.

Overall, staff were safely recruited and deployed in sufficient numbers to meet people's needs. Staff received a thorough induction and completed mandatory training to enable them to carry out their job roles effectively. The provider understood the need to arrange specialist training to enable staff to understand and meet the needs of people who were living with dementia.

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.

People received a responsive and person centred service. There were effective systems in place for staff to escalate any concerns they had about people's health, ensuring appropriate input and advice from relevant health professionals was sought and acted upon. Relatives were positive about the care and support their loved ones received and told us staff go above and beyond to ensure their loved ones are well cared for. People received sensitive support to maintain their privacy, dignity and independence.

The provider understood the importance of making information accessible. Staff were committed to ensuring they could communicate with people effectively.

Processes were in place to gather feedback from people and relatives. We found feedback was used to improve the quality of the service. There was an effective complaints management system in place. Staff told us the manager was approachable and listened to any concerns they had.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

This service was registered with us on 18 August 2021 and this is the first inspection.

The last rating for the service under the previous provider was good, published on 6 November 2018.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

Recommendations

We have made a recommendation about the analysis of accident and incident trends. Please see the well led section of this report.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.