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.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 safety culture based on openness and honesty. Staff listened to safety concerns, investigated incidents and reported safety events. Lessons were learned, and good practice was continually identified and embedded.

The registered manager and provider were responsive to feedback and actively used comments from people, families and professionals to drive improvement. Systems were in place to ensure lessons were learned across the organisation, and these were shared with staff through notice boards and daily ‘huddle’ meetings.

The provider worked with people and healthcare partners to establish and maintain safe systems of care. Safety was effectively monitored and managed, and continuity of care was maintained, including when people moved between different services.

Systems were in place to support smooth transitions between services when required. Staff had a good understanding of people’s needs and were able to identify when someone became unwell and needed medical support. During the inspection, we observed that when one person went to hospital, staff provided a clear and accurate handover of concerns and the person’s needs to the medical team.

Staff also supported people to attend community appointments and ensured their needs were met. This included acting on identified needs, such as arranging specific equipment to support a person’s mobility.

The provider worked with people and healthcare partners to understand what being safe meant to each person and how best to achieve this. Staff focused on improving people’s lives while protecting their right to live safely and free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared any concerns quickly and appropriately.

People told us they felt safe and well supported by staff, and families were generally happy with the care their relatives received. People, families and staff all felt able to raise concerns about safety and were confident the registered manager would take appropriate action. Staff completed safeguarding training, understood their responsibilities and had access to clear policies and procedures.

Where people lacked capacity, mental capacity assessments and best‑interest decisions were in place and involved relevant people. However, further work was needed to ensure a consistent approach to assessments. Where people lacked capacity and were subject to restrictions, applications to the Deprivation of Liberty Safeguards (DoLS) had been made. Where conditions were in place, this information was readily available to staff within the care plans.

The provider worked with people to understand and manage risks in a holistic way. Staff delivered care that was safe, supportive and enabled people to do the things that mattered to them.

Risk assessments were completed and reviewed regularly, and care plans included detailed guidance to help staff reduce risks. People and their families were involved in these discussions. There was a positive approach to risk-taking, and people were encouraged to take informed, positive risks to support their wellbeing, with input and support from the staff team.

We spoke with the registered manager about ensuring relevant information in care plans was easily accessible. The registered manager acknowledged that further work was needed to ensure care plans were fully person-centred and work was already underway to ensure these were updated. Discussions with staff demonstrated that they had a strong understanding of people’s preferences, wishes and the best ways to encourage and support them.

The provider detected and controlled potential risks within the care environment. Equipment, facilities and technology were maintained to support the delivery of safe care.

Systems were in place to ensure the premises and equipment were routinely checked and suitably maintained.

Rooms were spacious and generally free from clutter and trip hazards, which helped people move around the building safely. People were able to personalise their bedrooms, and suitable equipment was sourced when required.

On the first day of our visit, we found that some specialist airflow mattresses were not set to people’s current weights. This was addressed promptly by the registered manager, who took immediate action to update settings, review systems and implement learning. No one had come to harm as a result.

Work was underway to update the décor throughout the home, including steps to make the environment more dementia‑friendly and easier for people to navigate. People and families commented positively on the environment. People had ready access to outdoor space, including a secure courtyard.

The provider ensured there were enough qualified, skilled and experienced staff who received effective support, supervision and development. Staff worked well together to provide safe care tailored to people’s individual needs.

People were generally supported by a consistent staff team who knew them well, and people spoke positively about most staff members. The registered manager had recently recruited several new employees to reduce the need for agency staff, and these new staff were in the process of completing their induction. The service also had a bank of nurses available to cover shifts and had not needed to use agency nurses for some time. This helped ensure that people received continuity in the care they received by staff who were appropriately training and competent. Suitable recruitment processes were being followed.

Staff spoke positively about the training and support they received. The provider continued to ensure staff completed all training required for their roles and for meeting the needs of the people living at Acer Mews. Systems were in place to ensure staff were competent to deliver care, including in specialist areas. Staff told us they felt well supported, received regular supervision and were encouraged to develop within their roles.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns promptly with the appropriate agencies.

The home was clean and tidy, and any unpleasant odours were quickly addressed. People looked well cared for, and there was evidence they were receiving regular personal care and support with oral hygiene. We observed that staff used personal protective equipment (PPE) appropriately, and processes were in place for people who were at higher risk of developing infections due to health conditions.

There were suitable systems to manage dirty laundry and minimise the risk of cross‑contamination. Staff had completed training in infection prevention and control. Equipment was in place to further support the deep cleaning of bedrooms and other areas.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Medicines were stored safely and securely with temperature monitoring in place for areas where medicines were stored. Controlled drugs were stored securely with restricted access and records were completed accurately.

Electronic medication administration records (eMAR) were completed appropriately and provided assurances that service users were receiving their medicines as prescribed.

Written protocols for medicines that are administered ‘when required’ were available and provided details on how to support service users’ needs. The care plans reviewed were detailed, person centred and had sufficient information for care providers on how to support service users to manage their conditions.

For Service Users who required their medicines to be administered covertly (where medicines can be hidden in food or drink), crushed or via a feeding tube, staff had good knowledge of Service User requirements. There was detailed information available on how to do this and supporting documentation was in place.

Staff communicated effectively and used a multidisciplinary approach to support people with complex needs, including those with complex mental health conditions and diabetes.

The application of medicated patches was clearly recorded and ensured the patch application site was rotated in accordance with manufacturers guidance. Body maps were used to support and document the application of creams and risk assessments were in place for flammable emollients.

The recording of the administration for time specific medicines and bowel monitoring was sometimes unclear or inconsistent and could be improved for clarity.

Training and competency assessments were up to date for all staff administering medicines and there was a system in place to identify when training was due in advance to allow time to arrange completion.

Medicines related errors and incidents were recorded thoroughly with details of the incident, investigations, actions, and lessons learned. Learnings from medicines related incidents were incorporated into a monthly bulletin and shared with all staff.

Audits were conducted monthly and were comprehensive. Any areas for improvement identified through auditing were acted upon and reviewed to ensure the expected outcome had been achieved.

Staff had good knowledge of service user requirements and there was good oversight of medicines.