Archived: Acorns Care Centre

Acorn's Care Centre is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

The home provides single occupancy bedrooms with en-suite facilities across three floors, and is serviced by one lift. There is a communal lounge on the middle and top floor and a large dining area on the ground floor. At the time of the inspection there were 32 people living at the home.

We completed an inspection in November 2017, when the home was rated as inadequate and we took enforcement action. In July 2018, the issues raised in November 2017 had been remedied but we identified further concerns which meant we were not confident to withdraw our enforcement action at that time. We made the decision to undertake a further unannounced inspection within three months of our July 2018 visit to determine the concerns had been addressed and the quality of care provided had continued to improve.

In July 2018, the home had been rated as ‘requires improvement’ overall and in the key questions, safe, effective, responsive and well-led. Caring was rated as ‘good’. We identified three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 regarding; safe care and treatment, meeting people’s nutrition and hydration needs and good governance. We also made a recommendation regarding staffing.

Our re-visit in October 2018 was positive. At this inspection, we found the previous concerns raised in November 2017 and July 2018 had been addressed but identified new concerns regarding medicines. This meant there had been further breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014; safe care and treatment and good governance. The overall rating of Acorns Care Centre remains ‘requires improvement’ but effective and responsive have improved to good following this inspection.

Because of the significant improvements identified, we have withdrawn the enforcement action taken regarding the home following our November 2017 inspection when the home was rated inadequate. We have completed our enforcement action taken against the registered manager and cancelled their registration with CQC. The home continues to be supported by the local authority through a service improvement plan (SIP) and we attend meetings bi-monthly to monitor the homes progress.

At the time of our inspection, there was no registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. A home manager from the consultancy firm (caresolve) brought in by the provider to support the home to make progress commenced in post in July 2018. The home manager attended the home four days a week. Recruitment for a permanent nurse manager who would register with CQC was ongoing at the time of inspection.

We found past failures to assess risks relating to bed rails and airflow mattresses had been addressed. Since our last inspection, divan beds had been replaced by profiling beds with built in bedrails. Airflow mattresses were checked to ensure they remained on the correct setting for the person’s weight to reduce the risk of the person developing pressure areas.

At this inspection, we found medicines were not managed safely. There was medication administration charts (MAR) without photographs, missed signatures and medicines that could not be determined as being given. Cream records didn’t demonstrate creams were being applied as prescribed.

The system implemented to investigate and respond to accidents and incidents remained effective. This continued to be disseminated to staff to promote learning.

Recruitment was effective and appropriate checks completed before new staff commenced working at the home. Recruitment was ongoing for nurses and care staff and we observed interviews being completed whilst undertaking the inspection.

Staffing was determined using a system based on people’s needs but we previously made a recommendation about this as the calculation didn’t take in to account the logistics of the building. Prior to us undertaking the inspection, the staffing numbers had been increased and we will continue to monitor this through the SIP meetings.

People’s hydration needs were being met. Documentation had improved since the last inspection in July 2018 and there was no longer gaps on the records for the time of day drinks were being offered. People’s recommended daily fluid intake was being achieved.

Staff received an induction and appropriate training and supervision to support them to fulfil the requirements of the role. People told us staff knew what they were doing and met their individual needs and wishes.

People living at the home and their relatives were complimentary about the care provided. Staff and people spoke with fondness about each other and people’s preference and choices were upheld by staff that knew people’s likes and dislikes. People were treated with kindness and respect. Staff promoted people’s independence and ensured their dignity was maintained.

People had been involved in their initial assessment and development of their care plans. However, the nursing staff remained responsible for completing all the care plans and daily notes which meant some details were missed. Senior care staff had been appointed and they were receiving training to undertake some of these duties.

Feedback had been sought from people, relatives and staff. Resident and staff meetings were held on a regular basis which provided a forum for people to raise concerns and discuss ideas.

The home has improved and there were clear plans and identified timeframes to continue that trajectory of improvement. The home will continue to be monitored through the SIP which is in place to support the management to address the outstanding requirements.

We undertook an unannounced inspection at Acorns Care Centre on 10 July 2018 and returned for a second announced visit on 13 July 2018.

Acorn's Care Centre is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The home provides single occupancy bedrooms with en-suite facilities, across three floors, and is serviced by one lift. There is a communal lounge on the middle and top floor and a large dining area on the ground floor. At the time of the inspection there were 32 people living at the home.

At our last inspection in November 2017, the home was rated as ‘inadequate’ overall and in the key questions, safe and well-led. The home was rated as ‘requires improvement’ in effective and responsive and caring was rated as ‘good’. We identified seven breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in regard to; safe care and treatment (two parts), safeguarding, environment and premises, staffing and good governance (two parts). As a result of our findings, Acorns’ Care Centre was placed in special measures.

Enforcement action was taken following our November 2017 inspection and the outcome of this will be added to our report after any representations and appeals have been concluded.

At this inspection, we identified continued breaches of the regulations in relation to; safe care and treatment and good governance. There was also an additional breach of the regulations; meeting people’s nutrition and hydration needs. We also made a recommendation regarding staffing.

The overall rating of Acorns Care Centre has improved to ‘requires improvement’ which means the home is no longer in special measures.

A month prior to the inspection, the registered manager resigned so at the time of our inspection, there was no registered manager in post. A registered manager is a person who

has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Following our last inspection, the provider had commissioned a consultancy firm following our inadequate rating in November 2017. Up until a month prior to the inspection, the consultancy firm had been attending the home a couple of times a week but progress had been slowed due to the existing management arrangements. At the time of the inspection, the consultancy firm were responsible for the operational management and were a presence in the home five days a week.

A week prior to us undertaking our inspection, the consultancy firm had enlisted the support of a home manager that worked with the consultancy firm. The home manager would be at Acorns Care Centre to provide leadership and oversight four days a week, overlapping the director of the consultancy firm one day and the director being present the weekday the home manager wasn’t at the home to provide leadership and support. At the time of the inspection, recruitment was underway for a permanent home manager at the home that would register with CQC.

Following the inspection, we received an update from the consultancy firm detailing the actions taken to address the breaches identified. We will determine whether the home has made sufficient progress against the identified requirements at our next inspection.

At this inspection, we identified failures in respect of the delivery of safe care and treatment. This was because risks associated with bedrails and entrapment were not assessed and identified. We also found airflow mattresses were not on the correct setting based on people’s weight which increased the risk of people developing pressure areas.

A system had been implemented to investigate and respond to accidents and incidents. This was shared with the staff team to promote learning.

Staffing was determined using a system based on people’s needs. However, this didn’t take in to consideration the logistics of the building and that there was only one lift which meant supporting people to the dining room on the ground floor could only be supported one person at a time. We made a recommendation about this.

People’s hydration needs were not consistently met and people’s recommended daily fluid intake was not being achieved. It was unable to be determined how this had been addressed through the records maintained.

Staff received an induction and appropriate training and supervision to support them to fulfil the requirements of the role. People told us staff knew what they were doing and met their individual needs and wishes.

People had not always been involved with the development or review of their care plans. The nursing staff were responsible for completing all the care plans and daily notes which was burdensome on nursing staff but was in the process of being reviewed with the proposal of senior care staff to undertake some of these duties.

Feedback had been sought from people, relatives and staff. Resident and staff meetings were held on a regular basis which provided a forum for people to raise concerns and discuss ideas. Incidents and accidents were recorded, and consistently investigated.

Staff spoke positively about the consultancy firm and said they felt empowered to make changes. The home had improved and there were clear plans and identified timeframes to continue that trajectory of improvement.

We identified breaches of the regulations and found the scope of audits were not wide enough in scope to identify these internally through the consultancy firms audit process. Following the inspection, we were provided an update regarding the implementation of further audits to prevent re-occurrence of these issues. These audits will be considered as part of subsequent inspections to determine they have been embedded in to practice and achieved regulatory compliance.

Acorn’s Care Centre is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The home provides single occupancy bedrooms with en-suite facilities, across three floors, and is serviced by one lift. There is a communal lounge on the middle and top floor and a large dining area on the ground floor. At the time of the inspection there were 33 people living at the home.

Following our inspection in 22 and 26 February 2016 and 14 March at Acorns Care Centre, we took enforcement action and subsequently re-visited the home on 10 October 2016 and 12 April 2017, to ascertain if improvements had been made to the quality of care people received. At both inspections, we found the management had continued to make improvements to the quality of care people received and in April 2017, although there remained two breaches of the regulation in relation to staffing and governance, they were regarded to have little impact on people living at the home. As a result of the continued improvement observed, CQC withdrew the enforcement action we had previously taken.

Following our April 2017 inspection, we received anonymous information of concern regarding a mice infestation at Acorns Care Centre. The informant told us management were aware of the issue but had done nothing to address it. We passed this information to environmental health and they undertook a prompt inspection visit. Environmental health ascertained there was mice activity in several areas of the home including the kitchen and dining room. It was found, building repairs had not been made timely to prevent rodent access and pest control arrangements were ineffective in regards to the needs of the home. Environmental Health in collaboration with the provider put control measures in place to ensure people’s safety and continued to visit the home for the proceeding four days to confirm appropriate action was being taken. Environmental health undertook a follow up visit in October 2017 and further concerns were identified. We have considered their findings in May and October 2017 to inform our judgements.

At this inspection, we found seven breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in regards to; safe care and treatment (two parts), safeguarding, environment and premises and continuous breaches of the regulations for staffing and good governance (two parts). We are currently considering our enforcement options in relation to these breaches.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action.

Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special

At the time of the inspection there were two registered managers in post. However, following the inspection we were told one of the registered manager’s had stepped down and had submitted a notification to cancel their registration with CQC. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

All the people, relatives and visitors spoken with during the inspection said the home was a safe place to live. However, at this inspection, we found two people had not been protected from the risk of aspiration or choking. The two people had been assessed as having an 'unsafe swallow' but had been given foods that were not in keeping with their assessed needs which could have exposed them to the significant risk of harm.

Medicines were not managed safely due to processes being inconsistent, re-ordering of stock was chaotic and audits had not been conducted within required timeframes which would assist with re-ordering of medicines.

We found ineffective systems in place to safeguard people from abuse and improper treatment. During the inspection, we identified two events that had occurred which should have been referred to the local authority as safeguarding. However, neither incident had been referred; and one incident had been unknown to either registered manager.

There was a satisfactory recruitment process in place which included obtaining references and a Disclosure and Barring (DBS) check being undertaken before staff commenced working at the home. However, we identified the process of obtaining references required strengthening.

Staffing levels were no longer calculated using a formal calculation based on the needs of people using the service. We received mixed views from people, relatives and visitors regarding whether there were enough staff to meet people’s needs.

Following the inspection, we received the infection control audit and the service was rated 100%.

We saw the mealtime experience was positive and people were complimentary of the food choices and quality of the food provided. People’s nutrition and hydration needs were met but we found records to demonstrate this required strengthening.

The managers did not have an effective system in place to demonstrate compliance with the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards (DoLS). The registered manager had no system in place to undertake mental capacity assessment and oversee Deprivation of Liberty Safeguard applications. Granted authorisations remained on the computer and were not with people’s care files; the registered manager was unable to identify recommendations made and how these were being met to demonstrate compliance with the Act.

We found the system to oversee and schedule training was ineffective. Staff that weren’t due refresher training had been prioritised to attend the moving and handling training prior to people that had never completed the training at all. This meant staff were working without the required competence and skills to fulfil the duties of their role. Staff had not been appropriately supported by the management as they had not received consistent support through supervision and appraisal.

People’s biographical information, likes and dislikes was captured but had not been incorporated in to people’s risk assessments or care plans to support person-centred care planning.

People living at the home and their relatives described the staff as kind, caring and always willing to help them when needed. We found the staff were friendly and engaging which made for a relaxed and pleasant atmosphere. Staff were knowledgeable about the people they cared for and expressed being proud of the care they provided.

People were treated with dignity, respect and were given privacy at the times they needed it. We observed staff knocking on bedroom doors before entering and providing explanation to people prior to undertaking care tasks.

Staff had not received end of life training and despite being a nursing home, nursing staff were unable to manage syringe drivers and would require support from community nurses if a person needed this intervention and wanted to remain at Acorns Care Centre to receive end of life care.

The home had equality and diversity policies in place and the registered managers were able to demonstrate when they had been sensitive and supported people or staff’s cultural needs.

There was a complaints system in place and this was advertised throughout the home. All the people spoken with during the inspection expressed knowing the complaints process but informed us they had never had cause to make a complaint.

We found the operational structure had not been embedded and there was no oversight maintained in regards to managing the regulated activity. Audits were not completed in line with the regulations which meant issues were not being identified internally and addressed to ensure people were receiving safe and effective care. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

The service provides residential and nursing care as well as care for people living with dementia. The home provides single occupancy rooms with en-suite facilities, across three floors. There are two communal lounge areas located on the middle and top floor. The home has a large dining area on the ground floor. The home is serviced by one lift. At the time of the inspection there were 34 people living at Acorns Care Centre.

At our first ratings inspection in February 2016, we had found multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to; person-centred care, dignity and respect, consent, safe care and treatment, safeguarding service users from abuse and improper treatment, premises and equipment, receiving and acting on complaints, good governance and staffing. The home was rated as 'Inadequate' overall and in four of the five 'key questions' against which we inspected at that time. As a result of the findings, the home was placed in special measures and kept under review.

We returned to the Acorns Care Centre in October 2016. We found the service had progressed but breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 remained. This was in relation to safe care and treatment, complaints, good governance and staffing. The service was rated as requires improvement overall and in safe, effective, responsive and well-led.

During this inspection we identified continuing breaches of the regulations, which had been raised previously relating to staff training, supervision/appraisal and ensuring good governance. This meant we were unable to change the overall rating of the home. However, it is recognised that the home has made and sustained continued improvements and this has been recognised on each occasion we have returned to inspect Acorns Care Centre. Although the overall rating has not changed, the home is now rated as good in safe, caring and responsive. The home remains requires improvement overall and in the key questions effective and well led as a result of the outstanding breaches.

All the people we spoke with told us they felt safe living at the home. The home had suitable safeguarding procedures in place and staff were able to demonstrate that they knew how to safeguard people and follow the alert process. Appropriate employment checks had been conducted before new staff commenced employment in the home.

Processes were now in place for the appropriate and safe administration of medicines. Medicine records contained the required information. Since the last inspection, PRN protocols had been implemented and we observed their was sufficient medicine stocks within the home. Medicines were stored safely and in line with current guidance.

People had been consulted about their dietary requirements and preferences and we saw choice was given at every mealtime. We observed breakfast and lunch whilst conducting the inspection. Tables were laid with table cloths and condiments. We saw the meal time experience was not rushed and people were appropriately supported.

Staff told us they felt supported but we found staff had not received supervision as frequently as identified in the homes policy. Staff had not received an annual appraisal and we found gaps in staff training records. This was a continued breach of Regulation 18(2)(a) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found there were appropriate records relating to the people who were currently subject to deprivation of liberty safeguards (DoLS). There was documentation of techniques used to ensure restrictions were as minimal as possible. There were appropriate MCA assessments in place, which were linked to screening tools and restrictive practice tools which outlined the issues and concerns.

We observed people living at the home were living with sensory impairment, memory issues or living with dementia. We saw improvements had been made to the environment, pictorial signs had been purchased, a sensory room was available and themed corridors had been decorated in line with people living at the homes preferences.

People living at the home and their relatives were complimentary about the care provided. Staff and people spoke with fondness of each other and people’s preference and choices were upheld by staff that knew people likes and dislikes. People were treated with kindness and respect. Staff promoted people’s independence and ensured their dignity was maintained.

Each person who lived at the home had their own care file. We found care plans contained more person centred information but engaging people in the review process required further strengthening.

People were encouraged to maintain their relationships with friends and family. There were no prescriptive visiting times and friends and family were invited to activities when entertainers where scheduled. People were provided individual and group activities.

The activities coordinator was passionate about providing personalised activities and meeting people’s individual needs. There was a varied activities programme in place which was flexible and changed depending on people’s motivation. People told us their choices were respected and encouraged and that they felt the care received was responsive to their needs.

Staff told us morale was good and we observed staff were motivated and worked well together. We received positive feedback from people regarding the management and they told us that there had been significant improvements to the care received since our first inspection.

The complaints procedure was visible in the entrance to the home, in the lift and displayed outside the manager’s office. People and their relatives told us they knew how to make a complaint. They told us they were confident in the manager and we saw complaints had been resolved in the required timeframes.

We found some improvements had been made in regards to seeking people’s feedback regarding the quality of the service through resident meetings and surveys. However, this required further strengthening to capture feedback on all aspects of the care received to demonstrate suggestions for improvement were sought and then followed up and actioned.

We found offices were left unlocked and unattended which meant confidential information and records were not safely secured.

Positive feedback was received from staff about the management structure and the implementation of a team leader to the management team.

Records we looked at confirmed that CQC had received all the required notifications and we saw the inspection ratings were displayed in the foyer of the home.

At our previous inspection, we had found multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to; person-centred care, dignity and respect, consent, safe care and treatment, safeguarding service users from abuse and improper treatment, premises and equipment, receiving and acting on complaints, good governance and staffing. The home was rated as 'Inadequate' overall and in four of the five 'key questions' against which we inspected. As a result of our findings, the home was placed in to special measures which meant they would be kept under review.

Although we found the home had made significant improvements in several areas, we did identify continuing breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to medication, complaints, good governance and staffing.

We looked at how the service managed people’s medicines. At the last inspection on 23, 26 February and 14 March 2016 we had concerns regarding the suitable management of people’s medicines and this was a breach of Regulation 12(2)(f)(g) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At this inspection we found continuing breaches regarding medicines management. We found people were given most of their medicines at the times they were prescribed and systems had been implemented to ensure safe intervals between doses of medicines. However, we found antibiotics had not been administered prior to food and people had missed medications due to stock not being available. There was no information recorded to guide nurses when administering medicines which were prescribed to be given “when required” (PRN).

Cream records were inconsistent and we found creams that were required twice daily had only been signed by staff as administered once daily. Records regarding the use of thickeners were also inconsistent but staff were able to demonstrate that drinks and fluids had been thickened to the required consistency.

We looked at records of people’s food and fluid intake and found they were not always maintained accurately by staff. We saw food and fluid records were not completed as people ate their meal and felt that staff could not be sure what people had eaten when records were completed retrospectively.

Due to accurate records not being maintained, this meant there had been a continued breach of regulation 17 (2) (c) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to Good Governance.

At our last inspection, we found there were not sufficient numbers of staff effectively deployed to meet people’s needs. At this inspection, we observed staff responding to people in a timely way and observed a staff presence on each of the three floors of the building.

All the people we spoke with told us they felt safe living at the home. The home had suitable safeguarding procedures in place and staff were able to demonstrate that they knew how to safeguard people and follow the alert process. Appropriate employment checks had been conducted before new staff commenced employment in the home.

Staff told us they felt supported but we found staff had not received supervision as frequently as identified in the homes policy. Staff had not received an annual appraisal and we found gaps in staff training records. This was a continued breach of Regulation 18(2)(a) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We observed breakfast and lunch whilst conducting the inspection. Tables were laid with table cloths and condiments. We saw the meal time experience was not rushed and people were appropriately supported.

We found there were appropriate records relating to the people who were currently subject to deprivation of liberty safeguards (DoLS). There was documentation of techniques used to ensure restrictions were as minimal as possible. There were appropriate MCA assessments in place, which were linked to screening tools and restrictive practice tools which outlined the issues and concerns.

We observed people living at the home were living with sensory impairment, memory issues or living with dementia. We saw improvements had been made to the environment, pictorial signs had been purchased, a sensory room was available and there were further plans to make themed corridors.

People living at the home and their relatives were complimentary about the care provided. Staff treated people with kindness and respect. There was an identified dignity champion and people’s privacy and dignity was maintained.

Each person who lived at the home had their own care file. We found care plans were not person-centred and did not identify people’s individual goals. The care plans were prescriptive detailing how care was to be delivered and did not incorporate individualized, measurable and achievable goals. We have made a recommendation about person centred care planning.

We found that care plan reviews and evaluations had not been completed in conjunction with people. There were also inconsistencies in capturing and the recording of people’s life histories.

There had been an activities coordinator appointed since our last inspection and we saw that there was a comprehensive activities programme and social activities facilitated daily. People spoke positively about the activities programme and the changes that had occurred since the last inspection.

The registered manager was unable to locate the complaints file during the inspection so we were unable to ascertain progress made since our last inspection. This was a continued breach of regulation 16 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to complaints.

Staff told us morale was good and we observed staff were motivated and worked well together. We received positive feedback from people regarding the management and they told us that they would recommend the home to others.

We found some improvements had been made in regards to seeking people’s feedback regarding the quality of the service through resident meetings and surveys. However, this required further strengthening to demonstrate how suggestions for improvement were followed up and actioned.

We found provider audits had still not been implemented. The registered manager told us that a number of audits had recently been introduced but were not yet fully operative. This was evident in the continued breaches found during this inspection.

Prior to this inspection, the registered manager and provider had worked closely with the local authority to action shortfalls identified at our previous inspection. The registered manager was honest and transparent throughout this process and during this inspection. The registered manager acknowledged that further progress was required but recognised the improvements made and was complimentary about the staff and support received to achieve this.

The registered manager demonstrated a commitment to address the continued breaches in a planned and structured way. Following the inspection, we received confirmation that they had commenced addressing the shortfalls which we had identified at the end of our inspection.

Acorns Care Centre is registered to provide accommodation and support for up to 39 older people. The service provides residential and nursing care as well as care for people living with dementia. The home provides single occupancy rooms with en-suite facilities, across three floors. There were two communal lounge areas located on the middle and top floor. The home had a large dining area on the ground floor. The home was serviced by one lift. At the time of the inspection there were 36 people living at the home.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We conducted a scheduled inspection of the home on 08 October 2013 when we found the service was non – compliant with cleanliness and infection control and assessing and monitoring the quality of service provision. A responsive inspection was conducted on 02 December 2013 and the service was found to be non-complaint with records. A further responsive inspection was scheduled and undertaken on 18 March 2014 when the service were found to be compliant with all areas inspected

During this inspection, we found multiple breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014 in regard to person-centred care, dignity and respect, consent, safe care and treatment, safeguarding service users from abuse and improper treatment, premises and equipment, receiving and acting on complaints, good governance and staffing. We are currently considering our enforcement options in relation to these regulatory breaches.

People told us they felt safe but expressed concerns regarding staffing levels. We found that there was not enough suitably trained and experienced staff on duty to meet people’s social, emotional and physical needs. Staffing levels were not calculated using a formal calculation based on the needs of people using the service. We observed staff were ineffectively deployed which resulted in people’s care needs not being met.

People's medication was not managed safely and effectively. Medication was not given as per prescriber’s instructions and did not reflect best practice in some areas.

We identified serious concerns regarding risk management that we immediately fed back to the registered manager and we shared this information regarding our concerns with the local authorities safeguarding team and local commissioners to mitigate the risk of further harm occurring.

The service was not complying with the requirements of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards (DoLS). Mental Capacity assessments were not conducted. The registered manager had no oversight as to when Deprivation of Liberty Safeguards authorisations had been requested or granted. We found two granted authorisations which had expired. This meant that people were being deprived of their liberty unlawfully.

People told us the food was good but we found menus were not devised in conjunction with people at the service and was not reflective of people’s preferences.

The environment did not meet good practice guidance for supporting people living with dementia.

We observed incidents when people’s privacy and dignity was compromised and their confidentiality was breached. We also saw care records were kept in an unlocked cabinet in an unlocked office which was unattended by staff for large periods of the inspection.

Risk assessments and care plans were generic. People and their relatives had not been involved in initial assessments or reviews. People’s biographical information, likes and dislikes wasn’t captured to support person-centred care planning.

People were not supported to live full and active lives. There was no stimulation or attempts made to engage people in meaningful activity. People told us they would like the opportunity to go on trips but this had not been addressed by the management.

We were told that there had been no complaints received. We observed the complaint process was not visible within the home and we encountered difficulty obtaining a copy of the complaints policy. People living at the home told us they had expressed concerns and complaints but these had not been recorded or acted upon.

We found that there was no effective system in place to monitor and plan improvements to the service provided.

The provider did not have a system in place to assess the quality of the service. There were no audits carried out. We were told resident and staff meetings were conducted but there were no consistent records to determine actions identified during the meetings were followed up.

We identified significant shortfalls in the care provided to people at the home. This was linked to ineffective governance arrangements and leadership which resulted in the management having a lack of oversight regarding the home.

The overall rating for this service is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, they will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

When we visited on 20 March 2014 we completed a tour of the home and found that it was clean and free from odours.

We looked in peoples bedrooms and checked if they had been dusted and in toilets to see if they were clean.

We were unable to see evidence of audits taking place as the manager was on annual leave however the home was clean and did not have any odours.

At the visit on 20 March 2014 we looked at care plans for five people and found that all but one had been fully completed with signatures and dates of when these had been completed. They had been updated and all risk assessments had been completed

The people who lived at the home told us they were happy living there and they felt safe. The comments we heard included 'The staff are smashing. I couldn't wish for nicer staff'; 'The staff are all nice to me' and 'The staff are very helpful.'

We also had concerns about the procedures in place for ensuring that people were protected from the risks of abuse. There was a procedure in place and the staff members we spoke with were aware of their responsibilities in protecting vulnerable adults.

There was a complaints procedure in place and we were told that there had been no issues that had been dealt with through the formal complaints process in the last 12 months. Staff members were aware of the role that they had in managing informal complaints and concerns but there was no records of actions taken to resolve informal complaints and concerns.

We also checked the process for completing and managing people's records with the home. We found that records were not always accurate and there was not a clear process in place for storing and destroying records that were no longer required. We have asked the provider to make improvements about this.

During our inspection we saw staff asking people for permission to carry out care tasks in a polite and friendly manner. We found that people's needs were being met in a timely manner and that staff treated people with dignity and respect.

We saw that there were effective recruitment procedures in place and there were sufficient numbers of suitably qualified staff on duty to meet people's needs.

We were concerned that the home was not as clean as we would have expected. The provider and the manager had taken some action about this but it had not resulted in sufficient improvements. There was a quality monitoring system in place but this had not been fully effective in addressing the problems and issues that had been identified. We have asked the provider to take action about this.

We found staff had a pleasant manner and spoke to people in a way that maintained people's dignity and self respect.

People told us: "I like it here, the staff are always cheerful, this is not just for your benefit they are always this happy". "The girls and lads are always busy but not too busy to stop and make sure you don't want anything. They smile all the time and are polite to everyone". "I ask and I get you can not fault it here".

A relative we spoke to told us: "I come everyday at lunch time and have never seen anything but smiling faces. When my X moved here I was apprehensive, we had had a bad experience elsewhere but the move was the right one I am happy with the care here. They asked me what she likes and doesn't like and they are really good with her. I go home knowing she is safe and well cared for and that's a weight off my mind".

Acorns Care Centre had recently been inspected from local authority with only minor recommendations identified.

Student nurse placements were facilitated within the home from the local university, this group of staff gave positive feedback on their experience.