Acer Mews

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 newly registered 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.

The service was in breach of legal regulation in relation to how people were being supported with their medicines.

This service scored 59 (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 based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The provider had suitable systems to ensure lessons were learnt and shared with staff. The provider also shared organisational learning and learning from the wider health care setting. It was not always clear that following an incident, related care plans had been reviewed to ensure they remained relevant and some of the recent lessons learnt at service level lacked specific information to demonstrate how incidents, such as medicines errors or accidents were investigated to ensure all learning had taken place. Historically, concerns had not always been effectively addressed but we noted that since the registered manager was in post, improvements had been made and people and families were growing in confidence about the service.

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.

The provider worked with other health care services to ensure people’s care needs were met. One relative commented, “They [staff] are helpful here and good with getting [family member] to appointments and things.”

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 concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

People and families told us they generally felt people were kept safe. One person commented, “The staff are mostly nice and I feel safe.” A relative told us that following an incident, “The manager did get on it right away and all the staff have been retrained.” However, people and relatives did raise some concerns, with one person saying, “With the staff it can depend on the mood they are in. Some are good, others aren’t.” Staff generally had a good understanding of people and how to keep them safe but acknowledged that there were some staff who needed more training. The registered manager had recently commenced in post and was making steps to improve the safety of the home, but these processes needed to be further embedded. The provider told us they had developed open and positive relationships with the local safeguarding team.

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.

Care plans were in place and these contained sufficient detail about people’s needs and risk. There was evidence that where people wished, either they or their family had been involved in discussions around their care. However, we noted the quality of care plans varied across the two units, with some being more detailed and personalised than others. We also found some instances where risk assessments had not been completed accurately and where relevant care plans did not contain the most accurate information about people’s risk, such as a recent fall, and had not been reviewed following an incident.

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

The home was extensively refurbished in 2023 before opening as a newly registered care home, and routine checks ensured the premises, equipment and environment were maintained. People were cared for in a safe environment, which was designed and adapted to meet their needs. Further work was needed to ensure the environment was homely and supported people living with dementia. Work to make the garden environment dementia friendly with a sensory panel was underway with further plans for the internal and external environment in review.

Staff were appropriately trained in fire and evacuation, and simulated evacuations had taken place.

On-site maintenance staff completed safety checks and were able to deal with repairs. Appropriate contractors carried out routine servicing with all certificates up to date at the time.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

We were not assured that staff were always appropriately deployed. One person commented, “Things here are on and off. The staff are helpful, if they can help you, they will. I think they need more staff though. They sometimes use agency staff. If one is sick, it can hinder my day if I had plans.” A member of staff told us “I don’t feel there are enough staff to meet people’s needs. Some people needs several staff for care, and that makes it difficult if other people need support. Staff are always on the go.”

The provider was unable to demonstrate monitoring of response times to call bells. We found that the functionality of the provider’s call system was checked monthly, however response times were not audited, and we were not assured the provider had appropriate oversight in this regard to ensure that staffing levels were appropriate.

There was ongoing recruitment to ensure minimal use of agency staff, and new staff were due to start the induction process. This will ensure consistency of care for people within the home.

The service had a robust recruitment process. This included establishing employment history and reference checks as well as Disclosure and Barring Service (DBS) checks.

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 home was clean and tidy and domestic staff worked throughout the day to keep the home clean and complete regular cycles of deep cleaning. Staff were seen to use PPE appropriately. A family member commented, “The cleaning here is good, the washing is good and [family members] personal care is brilliant.”

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

Medicines were managed by staff who had been trained and had their competency assessed.

Medicines were stored securely and areas used to store medicines had the temperature monitored. On the day of the inspection, we found a tub of powder used to thicken drinks for people at risk of choking was in an unlocked cupboard, however this was rectified immediately by staff.

For people who had their medicines crushed prior to administration there were written instructions available to staff to ensure these medicines were administered in an appropriate and safe way, however staff told us they did not always follow the written instructions.

People were not always administered medicines as prescribed. We found gaps in the EMAR (electronic medication administration record) and found one person received doses of paracetamol too close together. We could not be assured that people received their medicines safely as prescribed.

For people prescribed medicine patches there was not always a record of where this had been applied to the body. When it had been recorded it showed that staff had not always followed directions on where to apply.

Although instructions for medicines that were given when required were available, they did not always contain person-centred information.

Although the service was carrying out audits of medicines management these had not always picked up on some of the issues found during the inspection.