Acacia Lodge

Updated 14 July 2022

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 Care Act 2014.

Inspection team

The inspection took place over several weeks, with visits to the service on two days, 20 April and 10 May 2022. The team consisted of one 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. The Expert by Experience visited the service on 20 April 2022 to speak with people living there. Phone calls took place to people’s relatives to request feedback in the week following the inspection visits. These were undertaken by the inspector and the expert by experience.

Service and service type

Acacia Lodge 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.

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 not a registered manager in post. A new manager had started in post in January 2022 but had not applied for the post of registered manager at the time of the inspection.

Notice of inspection

The inspection was unannounced.

What we did before the inspection

We reviewed the information we held about the home which included statutory notifications and safeguarding alerts.

The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.

During our inspection

We spoke with six people who lived at the service. We also spoke with the current manager, the director, the recruitment and training officer and the personal assistant to the director. We spoke with three care staff and the chef.

We looked at 11 care records and two staff files. We looked at various documents relating to the management of the service which included medicine administration records, staff training, supervision records, infection control and quality assurance records.

After the inspection

We spoke with four relatives to get feedback on the service.

We liaised with the local authority both prior to the inspection and after the inspection and continue to work in partnership with them to support the service. We were unable to get feedback from other health professionals.

Updated 14 July 2022

About the service

Acacia Lodge is a residential care home providing accommodation and personal care to 18 people at the time of the inspection. The service can support up to 32 people. The home also provides a respite service. The service supports a range of people, some of whom have dementia or mental health needs as well as physical health needs.

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

People and their relatives told us staff were kind to them and they felt safe.

Since the last inspection we found some improvements had been made to the quality of the care people received. However, we still found concerns with some aspects of record keeping for people at risk of dehydration or malnutrition. We also found the electronic care planning system was not up to date for all of the people using the service, and some risks still lacked guidance for staff.

Some people still did not have an up to date mental capacity assessment in place. The service could not evidence people were always supported to have maximum choice and control of their lives. Although staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service did not always support this practice.

Since the last inspection a new manager had been appointed but they have not applied yet to be the registered manager. The manager is working with the provider to establish more effective systems but there remains some areas that still require improvement.

Improvements had been made to the audits carried out by the management team. We saw medicines audits, infection control audits and building maintenance checks were being carried out.

Since the last inspection new care staff had settled into their roles and we were told recruitment was underway for additional management team members and administrative staff. Lack of key personnel had hampered progress against the action plan set out following the last inspection.

Recruitment was safe and there were enough care staff to support people.

People told us they enjoyed the food, and menu options had improved. This improved the overall dining experience.

We saw accidents and incidents were recorded more effectively and the provider representatives were reviewing trends in these to help staff understand patterns of behaviours, and minimise reoccurrence of incidents.

We saw evidence that appropriate medical personnel were contacted when issues of concern were raised, and we saw use of PPE had improved.

The ordering and storing of medicines was safe. We saw improvements to ‘as needed’ PRN protocols had taken place following the first day of the inspection.

Staff received the required training and support to carry out their role effectively through a mixture of online and face to face training. New care staff told us that they felt that the management team was supportive.

Rating at last inspection

At the last inspection we rated this service Requires Improvement. The report was published on 13 January 2022.

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

Breaches of legal requirements were found, and a Warning Notice was issued. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, the effectiveness of the service and the governance of the service.

Why we inspected

We carried out a comprehensive inspection of this service on 20 April and 10 May 2022.

This inspection was carried out to follow up on action we told the provider to take at the last inspection. This report covers all five domains.

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.

Enforcement and recommendations

We have identified a repeat breach in relation to nutrition and hydration. Whilst there were improvements in the management of the service, not all issues raised in the Warning Notice have been addressed. Therefore, we have identified a breach related to the governance of the service.

We have made a new recommendation in relation to the use of suitable recording for people with mental health needs.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.