Updated 8 August 2025
Dates of Assessment: 14 August to 03 September 2025. Acorn Lodge is a care home, providing accommodation, nursing and personal care to people living with varying stages of dementia and mental health conditions. The service can accommodate up to 47 people, at the time of our inspection 43 people were living at the service.
The provider was previously in breach of legal regulations in relation to dignity and respect from our inspection on 13 August 2019. Improvements were found at this inspection and the provider is no longer in breach of this regulation. At our last inspection on 13 August 2020, we made a recommendation about staff deployment and a recommendation about maintaining and reviewing people’s care records. At this inspection, improvements have been found in respect of staff deployment, however,we identified 3 breaches of legal regulations in relation to safe care and treatment, safeguarding and good governance.
In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.
Incidents and accidents were not always responded to, which meant staff and management did not always put actions in place to prevent reoccurrence. Risks to people’s health were not always assessed and mitigated which increased potential harm of people choking and sustaining injuries from bedrails. Where people displayed emotions of distress, their care records did not always contain information for staff to reduce incidents and protect others. People’s health needs were not always closely monitored to provide timely treatment and avoid hospital admissions.
Staff understood their responsibilities to protect people at risk of harm and abuse. However, processes and managerial oversight did not always identify concerns which required referrals to the local authority safeguarding team.
Equipment was serviced and checks of the environment were completed; however, the provider had not identified some window restrictors were ineffective.
Quality assurance processes did not provide a thorough oversight of the service. Inconsistent or incomplete care and staff records had not been identified through checks and audits. Where quality assurance processes had highlighted the need for person-centred details to be included in care records, this had not been completed in a timely way.
Other processes to check quality were effective. The registered manager looked for opportunities to improve the service by analysing complaints, requesting feedback and reviewing staff practices to ensure they were administering medicines within legislation and treating people with dignity. Staff were able to give suggestions, raise concerns, and told us managers listened to them.
People were now supported by staff who treated them with compassion and respect. People’s requests were now being promptly attended to and staff now engaged well with them.
Staff were regularly supervised and were given training opportunities to support them in their roles. The service was clean and staff used personal protective equipment appropriately.
Health and social care professional involvement was sought; however, their advice was not always included in people’s care records. People were able to access appointments from visiting professionals and externally.
People were supported by a staffing team who knew them well and understood their communication methods. People received person-centred care and engaged with a programme of activities. Although people experienced person-centred care, their care records did not always include information about what was important to them and staff’s knowledge about them.
People’s feedback was listened to, through surveys and meetings. People’s nutritional needs were met and their dietary requirements were known by staff.
People, their relatives, professionals and staff spoke highly of the registered manager and said they were visible and available to speak with if there were any concerns.