Acton Care Centre

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 people’s safe care and treatment. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There were effective systems in place for learning when things went wrong. Staff recorded all accidents and incidents, which were then investigated. The provider maintained a clear and structured process for documenting such events. These records were regularly audited, and any lessons learned were shared during team meetings.

Staff demonstrated a clear understanding of how to report incidents, accidents, and safeguarding concerns. They told us that management kept them informed about people’s needs and any changes to their care through team meetings and real-time notifications sent to their mobile devices, ensuring they were immediately updated while on shift.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. There was continuity of care, including when people moved between different services. 

The provider had systems and processes to support safe admissions and transfers of care. The registered manager assessed people before admission to ensure the service could meet their needs.

Staff were informed of people’s needs through electronic care plans and handovers.

The provider worked collaboratively with people and healthcare partners to understand what being safe meant to each individual, and how best to achieve that. Staff focused on improving people's lives while upholding their right to live safe, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. Concerns were shared promptly and appropriately.

Staff received safeguarding training and demonstrated a clear understanding of safeguarding principles and the procedures for reporting concerns. They expressed confidence that the management team would respond appropriately to any issues raised.

The registered manager submitted statutory notifications in line with requirements and worked in partnership with external agencies to help keep people safe. We saw evidence that recent safeguarding referrals had been made appropriately and in a timely manner.

The provider requested legal authorisations where restrictions amounted to a deprivation of liberty for people who did not have the capacity to consent to these. Decisions about people’s care were made in their best interests and for their safety. Where deprivation of liberty was put in place these were reviewed and were up to date.

The provider worked with people to understand and manage risks in a holistic and person-centred way. Staff delivered care that was safe and supportive, while also enabling individuals to engage in activities that were meaningful to them.

Care plans were detailed and included clear guidance for staff on how to identify and avoid potential triggers related to known risks for example, behavioural triggers or those linked to physical conditions and the appropriate steps to provide support. This level of personalised information demonstrated that individuals were at the centre of risk management planning.

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

Regular checks and audits took place to monitor all aspects of the safety of the environment.

The physical environment was maintained to a high standard of safety. Staff told us regular checks of the environment were conducted to identify and address any potential hazards, such as trip hazards or faulty equipment. Food preparation areas were clean and tidy.

Health and safety checks were carried out within the home. Maintenance records were maintained to ensure repairs were documented and actioned.

Staff told us they received fire safety, maintenance, laundry handling training regularly.

The provider ensured there were sufficient numbers of qualified, skilled, and experienced staff who received effective support, supervision, and ongoing development. Staff worked collaboratively to provide safe, person-centred care that met people's individual needs.

Relatives we spoke with were positive about the staff and their ability to meet people’s needs. Feedback included “ I can honestly say it’s a brilliant [home], I couldn't do better for [relative].” Another relative said “I see a load of staff when I go in—there are usually two at reception, and I can find staff if I need them, no problem.” A third relative said “They are really good and know what they are doing. I’m happy that [family member] is safe there—blimey, you couldn’t get better.”

The staff rota included nursing and care staff allocated to each unit. At the time of our assessment, Acton Care Centre was fully staffed. Staff told us they felt there were enough team members to meet people’s needs. One staff member explained, “Yes, [there is enough staff], because dependency depends on the ratio of residents.”

Staff received regular training, and completion was monitored by the provider. Competency checks were conducted and recorded. New staff underwent a structured induction programme, which included shadowing experienced colleagues, followed by ongoing training. Staff told us this helped them feel confident and well-prepared in their roles.

Recruitment systems and procedures were robust. We reviewed records for 10 staff members, which showed that thorough checks had been completed. This included Disclosure and Barring Service (DBS) checks, references, full employment histories, and appropriate risk assessments. A DBS check is a criminal record check performed by the UK's Disclosure and Barring Service (DBS) to help employers make safer recruitment decisions by revealing a person's criminal convictions and cautions.

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.

Staff had been trained in infection prevention and control and told us there was enough personal protective equipment (PPE) available such as gloves and aprons. There were effective processes to prevent and control infection. Staff knew how to manage infection outbreaks at the service.

There were audits in place to oversee the cleanliness and safety of the environment. There was handwashing signage and facilities throughout the building. There were appropriate clinical waste facilities and colour coded cleaning materials. Food safety was maintained. Kitchen monitoring checks were in place.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

The service could not be assured that medicines requiring refrigeration were being stored in line with the medicine’s product guidance. Fridge temperature monitoring was taking place, however, staff did not know how to record minimum or maximum temperatures or how to re-set the fridge thermometer.

Several people were receiving their medicines covertly, either crushed and mixed with food or yoghurt. Although there was evidence that a best interest meeting had taken place, there was sometimes no assurances that staff had authorisations from the pharmacist for crushing or mixing medicines with food. There was no robust process to ensure subsequent medicines that had been prescribed after initial authorisations, were appropriately assessed with clear instructions provided to be given covertly. This is not in line with the provider’s own policy or national guidance.

Some people were unable to swallow and needed to receive their medicines via a feeding tube. It was not always clear from the medicines administration record (MAR) that the medicines had to be administered in a tube.

We found most care plans had listed people’s medicines, but these were not kept up to date. This meant risks associated with newly prescribed medicines might not have been appropriately assessed and mitigated. There was also a risk that people’s health needs and medicines were not accurately reflected when passing care to other health care professionals, such as paramedics, which could impact safe care. One person was taking a medicine that interacted with many food types and there was no reference to this in the care plan and what action was needed to mitigate this risk.

‘As required’ medicines (PRN) protocols were in place for prescribed medicines. However, one person’s care plan stated giving a PRN medicine orally in the event of an emergency although the person was not able to swallow. While the staff members involved in the person’s care were aware that they were unable to swallow, staff who may not be familiar with the person may not administer the medicine safely in the event of an emergency. PRN medicines for people when they expressed agitation or distress were used only when the appropriate criteria were met.

Medicines, including controlled drugs, were stored securely and access to medicines were restricted to authorised staff only. Staff carried out daily controlled drugs checks. Staff were knowledgeable on peoples’ medicines and specific requirements. Body charts were in use for people prescribed topical medicines such as patches and creams.

Staff were trained on medicines management and received competency checks. They were able to explain people’s medication needs, when we asked them.

People told us they were happy with the support they received with their medicines.