Acorn Lodge

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 requires improvement. At this assessment the rating has remained 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.

The service was in breach of legal regulations in relation to people’s safe care and treatment and safeguarding people.

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 had a proactive and positive culture of safety based on openness and honesty and some staff listened to concerns about safety. However, staff did not always report and investigate safety events. Lessons were not always learnt to continually identify and embed good practice. Staff did not always document incidents which resulted in injuries to people. This meant incidents were not always reviewed or investigated to mitigate ongoing risks and allow for lessons to be learned. Where incidents had been reported, there was an effective system in place to allow the registered manager to investigate, identify trends or patterns and take appropriate action. Following our feedback, the registered manager shared plans of changes to the reporting system to allow for better oversight of incidents so they could be responded to appropriately.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. Preadmission assessments were completed with people prior to them moving into the service. Information was also gained from people’s relatives and health or social care professionals. A relative told us, “Yes, an assessment was done. Like what [person] liked and about their past. There was another one about health. I completed forms with the lead nurse about [person’s] needs.” Where risks were identified, for example, skin integrity concerns, staff ensured required equipment was readily in place upon admission. Summaries of people’s care and medicine records were available should they move to another service or require hospital admission, which promoted a continuity of care.

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. They did not always share concerns quickly and appropriately. People and their relatives said they felt safe at the service. Staff received training on safeguarding and understood their role in protecting people. A staff member told us who they would report concerns to and said, “I would speak to nurse in charge, if needed I would speak to [registered manager], if not [director]. Outside I could go to West Sussex County Council and the police or CQC.” Although staff and managers were aware of the policy and their obligations, we identified incidents which had not been reported to the local authority. During the inspection, we raised 5 safeguarding concerns with the local authority. Staff and management worked within the principles of the Mental Capacity Act 2005 (MCA). Where people had a Deprivation of Liberty Safeguards (DoLS) in place, the registered manager oversaw authorisations to ensure they were in date and relevant. Imposed conditions, such as, regular medicine reviews were being met.

The provider did not always ensure risks were mitigated to people. We reviewed an incident where a person had climbed their bedrail resulting in a fall from bed, there was no assessment of risk conducted for bedrail safety prior to and following the incident. The person’s care records were reviewed by staff without the incident being noted and concluded that bedrails remained appropriate. There was no evidence checks had been made to ensure bedrail safety for the person, which left them at further risk. We also identified some other people did not have risk assessments conducted for the safety and suitability of bedrails. Records for people at risk of choking were not always clear and consistent for staff to follow. People’s care plans did not always align with the list catering staff held. This increased the risk of people being served unsuitable meals. We raised our concerns with the registered manager who provided assurances all records of people requiring bedrails and at risk of choking would be reviewed as a priority. We reviewed incidents of physical altercations between people using the service. A person with a known history of harming others during periods of distress had hurt 2 other people. We raised our concerns with the registered manager who told us professionals had previously advised to sit the person a distance away from their peers to reduce the risks. We reviewed the person’s care plan; there was no detail to staff about potential risks and the advice provided by professionals had not been included for staff to follow. This placed people at continued risk of harm.

The provider mostly detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Most environmental risks had been assessed and mitigated, for example, in respect of fire safety. People had up to date personal emergency evacuation plans (PEEPS) to guide emergency personnel on how much support people would require to evacuate the building. Checks on electrical equipment and water safety had been conducted. However, we identified the window restrictors were not fully effective and could be unlatched easily. We fed this back to the registered manager who said they would address the concern immediately. A relative commented on the environment and said, “It’s friendly, homely and clean and tidy. Not luxurious. They’ve just recently done some decorating [person] has some pictures on their sideboard. It’s kept lovely clean and tidy.” The registered manager shared plans of installing some new equipment for the bathrooms based on feedback from staff. Hoists and other equipment to support mobility had been routinely serviced.

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. The provider completed pre-employment checks prior to staff deployment, however, discussions held regarding gaps in employment histories were not always documented. Members of the management team told us they would review their processes to ensure the conversations were captured. Staff received training and supervision relevant to their role and additional bite-sized training courses were facilitated by nursing staff to ensure staff knowledge was up to date. A staff member spoke of their ongoing learning and development and said, “My supervisions are with [deputy manager] and sometimes with [registered manager]. If we need anything we ask at supervisions but we are able to talk to them if we need anything like training and they will arrange the training.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The service was clean, housekeeping staff were seen to be working hard. Following an infection outbreak, the registered manager had shared details with stakeholders and put measures in place, including barrier nursing to minimise further spread of infection. Most people and relatives commented positively on the cleanliness of the service, however, a relative told us they frequently had to remove used crockery and cutlery from their family member’s room when they visited.

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Medicines were administered by registered nurses who had completed training and had their competencies regularly assessed. People who required time specific medicines received them in accordance with their prescription. A relative told us, “They give [person] medication at the right time.” Relatives told us they were informed of changes to their family member’s medicines. The registered manager gave an example where staff had noticed adverse medicine side effects for a person, following a review the person was more alert. Medicine errors and near misses had been documented and responded to appropriately.