Acorn Care Solutions Ltd

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. This is the first assessment for this service. This key question has been rated requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

Records relating to people’s care and safety incidents were not sufficiently comprehensive to ensure safe care. The provider was in breach of 1 legal regulation relating to good governance.

This service scored 53 (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 did not always have a proactive and positive culture of safety. Lessons were not always learnt to continually identify and embed good practice.

The provider did not have effective systems to analyse incidents and identify ways to reduce risk of recurrence. There was a lack of evidence around how individual incidents were responded to, or wider work to analyse trends or themes with incidents over time. For example, there were several incidents relating to 1 person’s behaviour towards staff. There was limited evidence of how these incidents had been followed up. The person’s care plan did not reflect the risks and frequency of incidents, or detail strategies of how staff could identify and mitigate the triggers to behaviours.

The registered manager told us it was difficult to collect and analyse information using their electronic care planning system. This had contributed to incidents not always being thoroughly or promptly investigated. This reflected that there may have been lost opportunities to learn from safety incidents. In response, the deputy manager had now been delegated responsibility to investigate and collate information in relation to incidents. We saw more recent examples where record keeping was more detailed and required actions were complete.

People did not raise any concerns around the learning culture or any incidents which had occurred. Staff had a good knowledge of the right action to take in the event of safety incidents. This helped to minimise any harm or potential impact on people’s safety.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

There were shortfalls in the provider’s assessment processes and how they ensured continuity and safety for new care packages. In one example, the provider did not commence care services to a person, after agreeing the start date with commissioners. The registered manager had delegated the task of starting the package of care to another member of staff and was not aware of the issue. This reflected a lack of oversight of new care packages and failings in systems to ensure people always experienced safe transitions in their care. In response, the registered manager had put additional checks in place when care packages were due to start. This helped to ensure they commenced at agreed times.

We found mixed examples of how effectively the provider coordinated with other stakeholders as people moved between services. One person told us, “When I went into hospital, I was concerned no one would be there when I came home, but I was given reassurance care would be up and running and it was”. However, we received feedback from the local authority, who gave examples where the provider had not always started care packages at agreed times, escalated concerns around changing needs or shared updates with partners as required.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. The provider did not always share concerns quickly and appropriately.

There were shortfalls in systems to investigate and document actions taken in response to safeguarding alerts received. The provider’s safeguarding records reflected safeguarding concerns had been raised to the provider as far back as July 2025, with limited evidence of how concerns had been addressed or resolved. The provider was working with the local authority to help ensure all historical concerns were being addressed.

The local authority told us the provider’s response to safeguarding enquiries did not always provide them with assurances pro-active action had been taken to investigate concerns and keep people safe.

There were systems in place to safeguard people such as, non-entry policies. These helped to ensure people’s safety and welfare could be accounted for in the event they were not contactable at planned care call times. There were examples where these procedures had been followed to establish people’s wellbeing, but also 1 example where the correct protocol around non entry had not been followed, which had resulted in a person making a complaint.

People told us they felt safe receiving care from staff and reported no safeguarding concerns in relation to staff or the provider. Staff had a good knowledge around safeguarding and procedures to follow if they had concerns about people’s safety and welfare.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People’s care plans and risk assessments contained limited information about how specific risks should be managed and their involvement in managing these risks. For example, 1 person required support with repositioning due to risks around skin integrity. The care plan lacked specific detail about how often this support should be offered. Care records reflected little information about the support people received. Where the person had a limited number of care calls, the risk assessment did not document the person’s level of understanding and how they managed risks outside of support hours. However, staff were clear in how they supported the person to manage the risk during care visits by providing repositioning support.

Care plans in relation to fire safety did not always document how staff could keep people safe and how people managed the risks outside of support hours. For example, 1 person’s environmental risk assessment stated in the event of a fire, staff should close the bedroom door and leave the property. The risk assessment did not include any details around other measures considered to reduce the risk. For example, a referral to the fire and rescue service or details about how the person could independently manage this risk. In response, the registered manager told us they would advise the person to make a referral to the fire and recuse service for additional guidance to reduce the risk.

People’s risk assessments around blood thinners had limited detail about protocols to follow in the event they fall. For example, 1 person’s risk assessment did not instruct staff to seek medical advice after a fall. It only specified to seek advice after certain injuries, not considering the higher risk of internal bleeding. The registered manager told us they would review these risk assessments to ensure they reflected best practice guidance.

There were business continuity plans in place, which detailed how the service would respond to risks related to extreme circumstances, such as severe weather. The registered manager had a client priority list in place. This documented who was at most risk and how people’s care should be prioritises in an emergency.

The provider detected and controlled potential risks in the care environment. They made sure equipment supported the delivery of safe care.

People told us they had appropriate care related equipment, such as mobility aids. They said staff were confident in the safe use of this equipment. Staff told us they had received training in the use of specific equipment needed, which helped promote safe use. The provider kept a log of the care related equipment people used and when equipment was last serviced. This helped ensure equipment was in good working order and well maintained.

Staff had a good awareness of supporting people to promote home security. For example, ensuring people’s key safes were in good condition and keys were securely stored after care visits.

There was an out of hours telephone based ‘on call system’ in place. Senior staff who operated it. were able to access the electronic care planning systems remotely to coordinate care and respond to emergencies. People and staff told us this was effective and there was always a senior member of staff available.

The provider did not always make sure staff received effective training and ongoing development.

Most people were happy with the quality and competence of staff. However, people told us when regular staff were not available, replacement staff were not always as knowledgeable or motivated in their role. One person told us, “There are some who are well trained, but I had to explain what needed to be done to the new person that came today. This is really annoying.”

Staff did not always receive timely training updates in key areas of their role. For example, there were a considerable number of staff overdue for moving and handling training to ensure they remained skilled to undertake these tasks safely. However, staff confirmed they had previously received this training and felt confident carrying out this support. During the inspection, the registered manager sent CQC confirmation that more staff had subsequently completed updates, but a considerable number of staff were still overdue.

The registered manager was working to improve systems to monitor staff’s training needs to address shortfalls in the oversight of this area. They had acted in response to feedback from the local authority and had amalgamated staff’s training records, which going forward they would use to check when staff training updates were due.

The provider followed safe staff recruitment processes in line with requirements set out in regulation. This helped to ensure suitable staff were employed.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading.

People told us staff wore appropriate personal protective equipment (PPE) and followed good hygiene practices. This included wearing gloves during support with personal care and changing gloves between care tasks to minimise the risk of cross contamination.

Staff confirmed they had received infection prevention and control training and had a good understanding about good practice in this area. Staff confirmed they had supplies of PPE in place.

The provider did not always make sure that medicines and treatments were safe.

Although people did not raise any concerns around the support they received, there were shortfalls around care planning, care scheduling and the oversight of medicines administration records. This had resulted in people not always receiving their medicines as prescribed. However, staff we spoke to had a sound understanding of good practice in medicines administration.

Not all medicines administration records (MAR) had the required information as set out in best practice guidelines. For example, 1 person’s MAR did not have details about their prescribed medicines dose or route of administration. Another person was prescribed topical creams. Their records did not document the amount or area of the body where this cream should be applied. We also saw examples where the list of people’s prescribed medicines was not consistent across various parts of their care plans. Therefore, this increased the risk people may not be supported to receive their medicines as prescribed.