Acacia Bank Care Home

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question Inadequate. At this assessment the rating has changed to Good. This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff completed accident, incident, and falls records in good detail, enabling thorough review and analysis. This supported the service to identify trends, reduce risks, and improve outcomes for people.

Root cause analysis was carried out following falls and was detailed and reflective, allowing for robust monitoring and review. Post-fall analysis was completed in line with policy and demonstrated the service’s commitment to keeping people safe and learning from incidents.

Although no formal complaints have been received, there was a clear and up-to-date complaints process in place. This included an easy read version to support accessibility for people using the service. The policy outlined what people could expect and how complaints would be handled.

The system was well-designed and would support effective responses and learning should complaints arise. Documentation included space to clearly record actions taken and outcomes, showing a strong focus on accountability and continuous improvement.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored.

Assessments were completed with people and their appointed representatives prior to admission to ensure the service could meet people’s assessed needs. Where people require support from other health and social care professionals, appropriate referrals were made in a timely manner. Staff worked closely with all relevant parties to ensure smooth transitions into and out of the service. This included sharing relevant information to support continuity of care.

There were clear pathways in place for managing emergencies, and staff were confident in following these. People’s care was reviewed following incidents to ensure systems remain effective and responsive to change.

The service had policies and procedures that reflected current best practice, and staff understood how to apply them. Regular audits and checks helped to ensure these systems were followed consistently. As a result, people were supported in a safe and well-organised environment where their needs were proactively managed.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Safeguarding referrals were made promptly when required, and CQC notifications were submitted without delay. Information sharing with external agencies was clear, timely, and transparent, ensuring appropriate action could be taken to protect people.

Following any reportable safety events, the provider took immediate action and implemented learning to prevent recurrence. This reflected a strong commitment to a proactive and open safeguarding culture.

People and their relatives told us they felt safe living at the service. Staff understood their safeguarding responsibilities and knew how to report concerns. Records showed that safeguarding procedures were followed consistently.

The provider maintained a Deprivation of Liberty Safeguard (DoLS) matrix and kept accurate records of applications and their progress. Where restrictions were necessary to ensure safety, such as the use of bed or chair sensors, mental capacity assessments had been completed, and best interest decisions were in place. This demonstrated compliance with the principles of the Mental Capacity Act and ensured people’s rights were respected.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Individual risk assessments were in place and regularly reviewed, particularly following any safety-related incidents. These assessments were detailed and tailored to each person’s needs, helping staff to understand and respond appropriately to potential risks.

Care plans reflected people’s assessed needs and current risk levels, ensuring care was delivered safely and consistently. Staff demonstrated a good understanding of people’s individual risks and how to support them effectively. During the assessment, we observed safe working practices that promoted people’s wellbeing while encouraging independence where possible.

Relatives told us their loved ones had all the necessary equipment in place to help keep them safe. People using the service told us they felt safe and well supported.

The service involved people and their representatives in decisions about how risks were managed, balancing safety with choice and control. This approach supported people to live as safely and independently as possible.

The environment at the service was exceptionally well maintained and thoughtfully designed to promote both safety and comfort.

The service was attractively decorated and furnished to a high standard, creating a welcoming and homely atmosphere. The ground floor had been extensively refurbished, featuring a large open-plan lounge and dining area that offered a spacious, bright, and accessible setting for people to enjoy.

The layout of communal areas had been carefully considered to encourage social interaction, with chairs and coffee tables arranged in small, inviting groups. Dining tables were well presented with tablecloths, centrepieces, menus, crockery, and cutlery, contributing to a dignified and enjoyable mealtime experience.

People had access to a range of high-quality, purpose-built spaces including a new cinema room and café, which provided multiple opportunities for meaningful engagement and social activity at any time of day.

The environment was not only safe and functional but also demonstrably enhanced people’s quality of life, supporting both physical wellbeing and emotional comfort. People consistently told us how the thoughtful design and high standards of the service made a real difference to how happy, settled, and independent they felt.

Bedrooms were clean, warm, and well personalised, reflecting people’s tastes and preferences. This helped to promote a sense of ownership and comfort. The overall environment was not only safe and functional but also enhanced people’s quality of life, supporting both physical wellbeing and emotional comfort. This reflected a service that goes above and beyond in providing a safe, engaging, and high-quality living space.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Rotas showed a consistent and suitable mix of skills and experience across shifts, ensuring people were supported safely and effectively. Staff were visible, responsive, and unhurried in their approach, and people told us their needs were met in a timely and respectful way.

Staff were trained and competent in their roles. A training matrix was in place to monitor compliance, and staff received regular supervisions and appraisals to support their development and maintain good practice.

Recruitment processes were safe and robust. All required pre-employment checks were completed, including references and Disclosure and Barring Service (DBS) checks. Documentation relating to recruitment was well maintained and demonstrated a thorough approach to ensuring staff suitability.

The provider had also taken proactive steps to support future admissions by beginning to recruit additional bank staff. This forward planning helped to ensure continuity of care and adequate staffing resources as the service grows.

Overall, the service had safe staffing arrangements in place, supported by effective recruitment, training, and oversight processes.

The service had effective infection prevention and control (IPC) measures in place to keep people safe.

The environment was clean, well maintained, and free from unpleasant odours. Regular cleaning schedules were in place and records showed these were consistently followed.

Staff had received appropriate training in IPC and demonstrated good understanding of how to prevent the spread of infection. During the assessment, we observed staff using personal protective equipment (PPE) correctly and practising good hand hygiene.

There were clear policies and procedures in place aligned with national guidance. The service carried out regular audits to monitor cleanliness and infection control practices and acted promptly to address any areas for improvement.

People and relatives told us the home was always clean and hygienic. Overall, the service maintained a safe and hygienic environment, helping to protect people’s health and wellbeing.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

PRN (as required) protocols were in place; however, for medicines with variable dosing, the guidance was not sufficiently detailed to support safe administration. For example, where people had been prescribed Laxido for constipation, protocols did not reflect the prescriber’s instructions that 1 to 4 sachets could be given in a 24-hour period. There was no clear guidance for staff on when to administer additional doses, which could lead to inconsistency in care.

We also found that a time-specific medication for 1 person was not recorded accurately on the Medication Administration Record (MAR) chart. The prescriber had instructed the medication be given 30–60 minutes before food, but no administration times were documented, so we could not be assured it was given correctly.

We found 1 person did not have specific care plans in place for Clopidogrel and Glyceryl Trinitrate spray. These require individual care plans to comply with clinical best practice. Having individualised care plans for these high-risk medicines promotes safe practice, supports staff decision-making, and ensures people receive timely and appropriate care.

Despite these issues, other aspects of medicines management were safe. Medicines were stored securely, the treatment room and fridge temperatures were monitored regularly, and both areas were clean and hygienic. Stock checks were accurate, and all prescribed medicines were available for people.

Improvements were needed to ensure all medicines are administered consistently and in line with prescribers’ directions. We found no one was harmed by the shortfalls we found on assessment.

The provider was responsive to feedback from the assessment and had already started making improvements in the areas identified.