Acorn House - Croydon

Acorn House – Croydon is a residential care home providing personal care to up to thirty one people in one adapted building. The service provides support to older people, the majority of whom are living with dementia. At the time of our inspection there were twenty three people using the service.

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

Management and leadership of the service was not fully effective and consistent. The service did not have a current registered manager in post. Prior to the appointment of the current manager in June 2022, feedback from people, staff and healthcare professionals indicated the service was not being managed as well as it should have been after the previous registered manager left in November 2021.

After taking up their post, the current manager identified a number of areas the service needed to improve. They took action in response and appointed a deputy manager for the service, implemented a new records system, procured a new dispensing pharmacy to support the service and brought outstanding training and supervision for staff up to date. Some improvements had also been made to the external and internal environment to make the service a more comfortable and pleasant place for people to live.

However, more work was needed to improve management oversight of Deprivation of Liberty Safeguards (DoLS) applications to make sure these were submitted in a timely manner. This meant people were not consistently supported to have maximum choice and control of their lives and staff did not consistently support them in the least restrictive way possible and in their best interests; the policies and systems in the service at the time of this inspection did not always support this practice. The provider also needed to complete the refurbishment and redecoration of the home to fully meet the needs of all the people using the service.

People were safe at the service. Staff knew how to safeguard people from abuse and keep them safe from identified risks to their safety and wellbeing. There were enough staff to support people and meet their needs. Recruitment and criminal records checks were carried out on staff to make sure they were suitable to support people. Health and safety checks were carried out of the premises and equipment to make sure they were safe. The premises was clean and tidy. Staff followed infection control and hygiene practice to reduce the risk of infections.

People were involved in planning and making decisions about the care and support they required. People’s records set out their preferences for how their care and support needs should be provided. Staff were provided relevant training to help them meet people’s needs. Staff were well supported by the manager and encouraged to learn and improve in their role and to put people’s needs and wishes at the heart of everything they did.

People were supported to stay healthy and well. Staff helped people to eat and drink enough to meet their needs. We have made a recommendation about supporting people living with dementia to eat well. Staff made sure people took their prescribed medicines in a timely and appropriate way. Medicines were managed safely. Staff supported people to manage their healthcare and medical conditions and made sure people could access support from healthcare professionals when needed. The service worked well with other healthcare professionals to ensure a joined-up approach to the care and support people received.

People’s feedback indicated staff delivered good quality support. People and staff spoke well about the new manager. The manager and deputy manager undertook audits and checks to monitor, review and improve the quality and safety of the service. There were systems in place to obtain feedback from people, staff and others about how the service could be improved. Accidents and incidents were investigated and learning was shared with staff, to help them improve the quality and safety of the support provided.

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

Rating at last inspection

The last rating for this service was good (published 20 September 2019).

Why we inspected

We received concerns in relation to the quality and safety of care and support provided to people, records maintained by staff, the cleanliness and quality of the environment, staffing levels, staff competency and management and leadership of the service. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

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.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

We found evidence that the provider needs to make improvement. Please see the effective and well-led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Acorn House – Croydon on our website at www.cqc.org.uk.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Acorn House – Croydon is a residential care home which can support up to 31 people in one adapted building. At the time of this inspection, the service was providing personal care to 16 people. This service is located next door to Acorn Lodge – Croydon, a residential care home which is managed by the same provider. As a result, staff often work across both services.

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

The quality and safety of the service had improved for people since our last inspection. The provider had made sure people’s needs were assessed prior to them using the service to help plan the care and support they needed. People’s records were now accurate, current and contained detailed information about them and their care and support needs to help staff deliver personalised care. Senior staff reviewed the care and support provided to people to make sure it continued to meet their needs.

Staff recorded better information about people to help senior staff check for any potential issues with their health and wellbeing. Staff supported people stay healthy and well. They helped people to eat and drink enough to meet their needs and to take their prescribed medicines. Extra help was sought for people if they needed this, for example, when they became unwell. Recommendations from healthcare professionals were acted on so that people received the relevant care and support they needed in relation to their healthcare needs.

Staff were more caring and attentive to people and people told us their needs were met by staff. Staff supported people to maintain their dignity, privacy and independence. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. Activities at the service had improved and people were more stimulated and engaged. The provider was continuing to look at further ways to improve this aspect of the service for people.

Improvements had been made to recruitment practices to reduce the risk of people being supported by unsuitable staff. There were adequate numbers of staff to support people. People said they were safe. Staff knew how to safeguard people from abuse and how to manage identified risks to people to reduce the risk of injury and harm to them. Regular health and safety checks of the premises and equipment were undertaken to make sure they were safe.

Staff followed current practice when providing personal care and when preparing and handling food which reduced hygiene risks. Cleanliness and hygiene around the premises had improved since our last inspection and communal areas and people’s rooms were clean and tidy and free from odours. Some parts of the premises had been redecorated and there were a range of comfortable spaces for people to spend time in.

Staff received training to help them meet the range of people’s needs. The provider had identified that staff were not receiving regular supervision. All staff were scheduled to have a supervision meeting following this inspection. However, staff had opportunities to discuss their working practices at monthly team meetings. Senior staff used these meetings to make sure staff were clear about their responsibilities for providing high quality care and support to people.

People were comfortable raising concerns and making complaints when needed. The provider had improved the way complaints were handled to check these were dealt with in an appropriate way. Events and incidents were fully investigated and the provider kept people involved and informed of the outcome. Learning from investigations was acted on and shared with staff to help them improve the quality and safety of the support they provided. However, some decisions made by the provider in response to events and incidents did not always sufficiently protect the safety and wellbeing of people at the service. The provider was taking action to ensure future decisions would be focussed on keeping people safe from risks at all times.

The provider was now using their governance system effectively to monitor the quality and safety of the service. There were regular audits and checks of key aspects of the service and prompt action was taken to address any issues identified through these checks.

People, relatives and staff were encouraged to give feedback about how the service could further improve. The provider worked with other agencies to make improvements. They acted on recommendations made by others to improve the quality and safety of the service for people.

The service had not had a registered manager in post since May 2018. The provider had just appointed a manager for the service immediately prior to this inspection. As a result, it was too early to judge the effectiveness and consistency of their leadership of the service. However, the deputy manager had taken responsibility for ensuring all the necessary actions were taken to meet the breaches of legal requirements found at the last inspection.

Although the provider had acted to make improvements, it was too early to judge whether these could be maintained continuously over time. Many of the positive changes and improvements we found had been made in the months prior to our inspection which meant there was not enough evidence of consistent good practice over time.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 14 February 2019) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

At our previous inspection in April 2018 we found the provider was in breach of legal requirements relating to dignity and respect, need for consent, safe care and treatment, staffing and good governance. We rated the service 'requires improvement' overall and in each of the five key questions. Following the inspection, we asked the provider to complete an action plan to tell us what they would do to address the breaches of legal requirements we found.

At this inspection we found the provider had addressed the breaches of legal requirements relating to need for consent, safe care and treatment and staffing. However, they had not taken sufficient action to address breaches of legal requirements relating to dignity and respect and good governance. We also found additional breaches of legal requirements. The service remains rated 'requires improvement' overall and in each of the five key questions.

Appropriate recruitment checks were not made on staff to ensure they were suitable to support people. There were however enough staff to support people safely. Staff received relevant training to help them in their roles and they were encouraged to improve their working practices through supervision. But, there was no system in place to monitor that supervision took place at regular and appropriate intervals.

People’s needs were not always assessed when they started to use the service, so staff may not know how to support them in a safe and appropriate way. When people’s needs changed, reviews of their care were not done in a timely manner to check for any changes needed to the level of support they required. Information for staff on how people’s care needs should be met had improved. However, this was not consistent which meant some people may not receive personalised care that was responsive to their needs and preferences.

Staff had access to improved information about how to manage risks to people’s safety. Staff understood the risks posed to people and how they should support them to stay safe. Staff were trained to identify abuse and understood when to report concerns to the appropriate person. However, they were not always consistent when recording and reporting accidents and incidents involving people. Staff were still not maintaining accurate and complete daily records of the support provided to people.

People were still not being supported to maintain their dignity. Some staff did not speak with people as they supported them with aspects of their care. However, others were polite and kinder in their interactions with people. Staff appeared not to notice that people were not always clean and appropriately dressed. However, staff did respect people’s privacy when supporting them with their personal care needs.

Arrangements to support people with their health needs were not fully effective. However, staff liaised with visiting healthcare professionals and when people became unwell they sought appropriate support from them. People received their prescribed medicines as required. These were stored safely and securely.

People were supported to eat and drink enough to meet their needs. Menus had been revamped following consultation with people and their relatives to include more choice and options for meals that people preferred.

Activities provision at the service had improved. However, some staff were still not providing the level of engagement and stimulation for people that was expected. Staff supported people with their social, cultural and religious needs and to be as independent as they could be. There were no restrictions placed on people’s friends and relatives about when they could visit the service.

The provider had acted to make the premises safer for people. There was regular maintenance and servicing of the premises and of equipment used in the home, to check these remained in good order and safe to use. The environment had been improved to make this more suitable for people living with dementia. However, some areas like people’s bedrooms were sparsely furnished and lacked personalisation.

Most parts of the environment were clean and hygienic. However, some parts would have benefited from additional and more thorough cleaning. Staff followed good practice to ensure risks to people were minimised from poor hygiene and cleanliness when providing personal care and when preparing and serving food.

Staff were now aware of their responsibilities in relation to the Mental Capacity Act 2005 (MCA) and supported people in the least restrictive way possible. The policies and systems in the service supported this practice.

The provider continued to maintain arrangements to support people at the end of their lives. Relatives, where this was appropriate, had been included in discussions to ensure that end of life decisions were made with their involvement.

The provider maintained arrangements for dealing with people’s complaints. However, complaints were not responded to in writing, so people might not have been informed of their rights to take their complaint further.

The provider’s governance system was still not fully effective. No management audits or checks of the service had been undertaken since August 2018 and the provider had not identified the issues we found during this inspection with the quality and safety of the service. The provider had not sufficiently monitored progress against their own action plan to address the breaches in legal requirements we found at the last inspection.

Relatives felt the provider was not always open and transparent with them about management changes at the service. There was no registered manager in post. An acting manager had been appointed prior to our inspection. However, they had no prior experience of managing a care home. This was a temporary appointment and the provider intended to recruit a permanent, experienced manager for the service.

It was evident that the provider had made some improvements to the service since our last inspection. The provider had acted to capture the views of people and their relatives to identify how the service could be improved. The provider was continuing to invest in the service and planned to make further changes to improve standards and service quality.

At the time of this inspection the provider was continuing to meet regularly with the local authority as part of their ongoing contract quality monitoring arrangements. We noted that they responded to the local authority’s requests for information promptly and dealt with concerns in an appropriate way.

At this inspection we found the provider in breach of legal requirements with regard to person centred care, dignity and respect, fit and proper persons employed and good governance. We are taking enforcement action in relation to the breach of legal requirements with regard to good governance and we will report on this when our action is complete. You can see what action we told the provider to take with regard to the other breaches at the back of the full version of the report.

At our previous inspection on 21 and 23 February 2017 we found the provider was in breach of legal requirements relating to need for consent, premises and staff recruitment. We rated the service ‘requires improvement’ overall and for the key questions ‘safe’, ‘effective’ and ‘well-led’. They were rated good for the key questions ‘caring’ and ‘responsive.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to address the breaches of regulation and improve the key questions ‘safe’, ‘effective’ and ‘well-led’ to at least good.

At this inspection we found whilst the provider had addressed the breaches of legal requirements relating to premises and staff recruitment, they had not taken sufficient action to address the breach of legal requirement relating to need for consent. We also found additional breaches of legal requirements. The service remains rated ‘requires improvement’ overall and are now rated ‘requires improvement’ for each of the key questions.

The registered manager remained 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.

Staff did not always treat people with dignity and respect. Staff did not always speak to people politely and there was little interaction between staff and people. Some elements of the service were overly structured impacting on the flexibility of people’s preferred routine and choices. Staff did not adhere to the principles of the Mental Capacity Act 2005 and had not applied for legal authorisation to deprive people of their liberty.

A safe environment was not provided and risks to people’s safety were not adequately identified or managed. Accurate and complete records were not maintained about the daily support provided to people. Care records outlined people’s needs but at times these lacked detail.

The provider had not arranged for staff to receive regular training to ensure they had the knowledge and skills to undertake their duties and adhere to good practice guidelines.

A new governance framework had been introduced but this was not fully embedded and needed expanding to ensure it captured all areas of service delivery. There were no formal systems in use to capture the views of people and their relatives about the service.

Activities were available and staff had been encouraged to provide more stimulation and engagement for people. However, we found there was a lack of flexibility in the activity programme and it did not adequately take into account people’s individual interests. We recommend the provider consults national guidance on providing activities for people living with dementia. The provider did not make information accessible and we recommend the provider consults guidance about implementing the accessible information standard.

The provider had improved the environment. However, we saw further work was required to complete the refurbishment and redecoration plans. We recommend the provider consults national good practice about developing their environment to support the needs of people living with dementia.

Staff were able to describe signs of possible abuse and were aware of safeguarding adults’ procedures. On the whole we found safeguarding adults’ procedures were adhered to. We also found on the whole safe practices were followed to prevent and control the spread of infection and ensure a clean environment was provided. However, improvements were required in both areas to ensure adherence with good practice guidance.

Improvements had been made to ensure safe staff recruitment practices were followed and there were sufficient numbers of staff on duty.

People received their medicines as prescribed and safe medicines management processes were in place. People received support with their dietary and nutritional needs and staff arranged for people to receive support with their health needs when required.

Staff respected people’s privacy when providing personal care support. People’s preferences regarding the gender of staff supporting them was taken into account. Information about people’s religion, culture and sexuality was collected as part of the admission process and people were provided with any support required. There were no restrictions to visitors.

A complaints process remained in place and the deputy manager reviewed all complaints on a monthly basis to identify any trends and learning.

The service was currently in ‘provider concerns’ with the local authority and they were working with the local authority to demonstrate improvements with the quality of service delivery. The registered manager was aware of their CQC registration responsibilities and to submit statutory notifications about key events that occurred at the service.

The provider was in the process of recruiting to strengthen the management team across both this service and their sister service. We will assess the impact of this change at our next inspection.

The provider was in breach of legal requirements relating to need for consent, treating people with dignity and respect, safe care and treatment, staff training and good governance. You can see what action we have asked the provider to take at the back of the main report.

Acorn House – Croydon provides care and support for up to 31 older people, some of whom may be living with dementia. There were 22 people using the service at the time of our inspection.

The home had a registered manager in post who was present at our inspection. 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.

Acorn House - Croydon had been placed into a provider concerns process by Croydon Council owing to safeguarding and quality concerns. The ownership and management of the service was working closely with the Council and partners to improve the service delivery to people using the service. This joint working process was working well at the time of this inspection.

Staff had received training in the MCA (Mental Capacity Act) however improvements were found to be required around the application of the Act.

Bathrooms provided for people using the service presented poorly and were not well maintained. We found that people would also benefit from an accessible outdoor space suitable for their needs.

We also found improved arrangements needed to be put in place for the recruitment of staff. Staff records contained the required information however one staff member was working at the home without a completed criminal record check.

Staff received the training and support they needed to help carry out their job roles effectively. They had received training around safeguarding people from abuse and knew what action to take if they had or received a concern. They were confident that any concerns raised would be taken seriously by the registered manager and acted upon.

The service completed assessments of people’s needs and these were used to inform the care plan for each person. Records showed people’s needs were kept under review and changes were made as required.

People were supported to take their medicines as prescribed and to access healthcare services when they needed them.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Acorn House - Croydon on our website at www.cqc.org.uk.

We found improvements had been made around the management of medicines and ensuring that they were safely administered to people using the service. There were now appropriate arrangements in place for the storage, administration, recording and disposal of medicines. Medicines kept on behalf of people using the service were being administered correctly with up to date records kept.

We observed positive interactions between staff and people using the service during the course of our visit.

People told us they enjoyed the food provided at the home. One person said 'The food is exceptionally nice but it's not always well presented, apart from that I cannot complain'. Another person said 'The food is not too bad. I enjoy it most of the time'.

People told us about staff. One person said 'There are plenty of staff around, they do as much as they can for me and my wife'. Another person said 'I get on with everyone here and the staff are so nice'. A visiting relative said 'The staff are kind and even handed with everyone, my relative always looks well dressed and well looked after when I visit, there is always a nice kind atmosphere here'.

One person said 'I have nothing to complain about but I would tell the manager if I did have to complain, I have told the manager of some minor concerns in the past and they dealt with them straight away'. Another person said 'I would tell staff if I was not happy and they would sort it out for me'.

We found that some people using the service were not being supported to eat and drink in a sensitive manner that respected their dignity and ability.