Acer 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.

This is the first assessment for this registered service. This key question has been rated 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 culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff and leaders demonstrated a positive learning culture and used audits to support continuous improvement. Information was gathered, reviewed and analysed to identify where changes were required to enhance the quality and safety of care. Actions were implemented to address identified issues, and lessons learned were shared with staff to promote good practice and drive improvement across the service. We found some audits had not improved medicines management or care record accuracy. The provider assured us they were strengthening quality improvement processes to address this.

Accidents and incidents were appropriately reported, recorded and reviewed to identify themes, trends and opportunities for learning. For example, following a fall, a person agreed to trial using protective equipment. Staff understood their responsibilities for reporting accidents and incidents and were able to explain the importance of doing so in supporting learning and maintaining safety.

There were effective systems in place to ensure learning was embedded into practice. Staff told us ‘Learning Labs’ took place. This was an online meeting where lessons learned were shared. This was available to all staff and minutes of the meeting were shared with all staff. In addition, where changes to people's care or risk management plans were required, this information was communicated through handovers and team discussions.

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.

There were processes to support people to move into the service safely and in a person-centred way. Assessments were completed prior to admission to ensure people's needs could be met and any identified risks were understood and planned for. People and their relatives, where appropriate, were involved in planning care and support, helping to ensure risks were identified, assessed and mitigated from the outset. One relative shared how their family member had been reassured by staff and this had supported them to settle into the home. “They calmed [family member] and spent time giving [family member] support and reassurance. [Family member] very quickly became comfortable in his surroundings.”

Systems supported effective communication and information sharing when people moved between services. Relevant and up-to-date information was provided to healthcare professionals to support clinical decision-making and promote continuity of care. For example, if a person required emergency hospital treatment, detailed information about their health conditions, medicines, communication needs and support requirements accompanied them. This helped ensure professionals who may be unfamiliar with the person had access to essential information and could provide safe and appropriate care.

Staff understood the importance of effective transitions and told us they worked closely with people, relatives and external professionals to ensure changes between services were planned and coordinated whenever possible. This helped to reduce the risk of avoidable delays, misunderstandings or gaps in care, and supported positive outcomes for people.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

There were effective safeguarding systems and processes in place. The registered manager understood their responsibilities and acted appropriately when concerns were identified. Safeguarding concerns were reported to the relevant authorities and investigated where required, helping to ensure people remained safe and protected from harm.

People told us they felt safe. A person commented, "I have the lovely girls to help me and keep me safe. I never worry.” Another person told us they were safe because staff cared for them. These comments reflected the positive relationships people had with staff and the confidence they had in the support provided.

Staff demonstrated a good understanding of safeguarding and were able to explain the circumstances in which they would make a safeguarding referral and how they would do this. They understood the importance of acting promptly if they had concerns about a person's welfare. One staff member told us, “Safeguarding information is easy to find, it’s everywhere because we’ve been trained to protect people.” This showed staff recognised their role in keeping people safe and protecting them from abuse.

The service was working in line with the principles of the Mental Capacity Act 2005 (MCA). Where people required restrictions to keep them safe, appropriate legal processes had been followed. Deprivation of Liberty Safeguards (DoLS) applications had been submitted appropriately, and records showed mental capacity assessments had been completed where required. Best interest decisions were documented and evidenced involvement from relevant people and professionals. This helped ensure any restrictions placed on people were necessary, proportionate and lawful, while supporting people to have maximum choice and control over their lives.

The provider worked with people to understand and manage the individual risks they faced by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People were involved in managing risks to their safety and wellbeing wherever possible. Staff worked alongside people to help them understand risks and identify measures which promoted their independence while reducing the likelihood of harm. For example, one person had been supported to use specialist equipment to minimise the risk of injury. They told us, “It does stop me doing any damage.” This demonstrated how reasonable adjustments had been made in a way that maintained the person's dignity and choice.

Risk assessments were person-centred and completed to identify risks associated with people's individual needs. These were reviewed regularly and updated when changes in circumstances occurred. Care records contained clear guidance for staff on how identified risks should be managed and reduced whilst supporting people's independence.

Where risks had been identified, plans outlined least restrictive approaches to keep people safe. For example, strategies to reduce the risk of falls were clearly documented and focused on supporting people to remain as independent as possible while reducing the risk of avoidable harm. Staff understood the importance of balancing safety with people's rights, choices and preferences and involved people in decisions about how risks should be managed. This approach helped to ensure risks were proactively managed in a way which promoted people's safety, wellbeing and independence.

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

People were supported in a clean, safe and well-maintained environment. There were systems to identify, assess and manage environmental risks, and regular checks were completed to help ensure the premises remained safe for people, visitors and staff.

Environmental risk assessments covered areas such as fire safety, infection prevention and control, equipment safety and potential hazards within the home. Where risks were identified, action had been taken to reduce them and measures were kept under review to help ensure they remained effective. In addition, work to improve fire safety had been planned in response to feedback from the Lancashire Fire and Rescue Service. This demonstrated the provider responded to expert advice and information.

The environment was organised to meet people's individual needs and promote their independence. People had access to outdoor spaces and were supported to use these safely. Staff maintained appropriate oversight while respecting people's privacy, choice and freedom.

People had access to equipment to meet their assessed needs. Records showed equipment was routinely serviced and maintained to help ensure it remained safe and suitable for use.

Staff understood their responsibilities for maintaining a safe environment and knew how to report hazards or concerns. Emergency procedures were in place and staff were able to describe the actions they would take to support people safely in the event of an emergency.

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 had a robust recruitment process to identify staff with the values, skills and behaviours required to deliver high-quality care. Applicants attended an assessment day before interview, allowing managers to observe teamwork, communication skills and alignment with the organisation's values. Senior leaders said this approach provided a better understanding of candidates' strengths and compassion, helping to recruit staff committed to person-centred care and positive outcomes for people.

The provider followed recruitment procedures to ensure all required checks were completed before staff started work at the service. Enhanced Disclosure and Barring Service (DBS) checks were carried out. DBS checks provide information about convictions and cautions held on the police national computer. The information helps employers make safer recruitment decisions.

Staff were recruited safely and received the training, induction and support they needed to carry out their roles effectively. New staff completed a comprehensive induction programme which enabled them to develop the knowledge and skills required for their role and become familiar with the culture and values of the organisation.

As part of their induction, staff spent time working alongside colleagues from different departments. This helped them to gain a broader understanding of the various roles and responsibilities within the organisation and promoted effective collaborative working. Staff told us this supported them to understand people's needs more holistically and contributed to the delivery of person-centred care.

The provider offered a combination of face-to-face and online training and had considered different learning styles when developing training programmes. There were systems to support staff to develop and maintain their knowledge following formal training. For example, staff with additional expertise acted as champions within specific areas of practice and provided ongoing guidance and support to colleagues. One member of staff had completed enhanced training in falls management and was available to share knowledge, provide advice and help staff embed learning into practice. This contributed to a positive learning culture and helped staff develop confidence in their roles.

We observed there were enough staff deployed to meet people's needs safely. Staff responded promptly when people required support and delivered care in a calm, patient and attentive manner. Staff spent meaningful time with people and supported them at a pace reflective of their individual preferences and needs. People appeared relaxed, were not rushed and were supported to make choices about how they spent their day.

However, we received mixed feedback about staffing levels. Some staff, a person using the service and a relative felt additional staffing would be beneficial during particularly busy periods. The provider responded positively and reviewed and amended the staffing arrangements to ensure people’s needs and preferences could be met in a timely way.

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.

People were supported in a clean, safe and hygienic environment which helped to reduce the risk of infection. The home was visibly clean, well maintained and free from unpleasant odours. There were processes to monitor and maintain standards of cleanliness, including cleaning schedules and regular checks to ensure cleaning tasks were completed consistently.

People spoke positively about the cleanliness of the service. One person told us, “The ladies keep my room very fresh.” Another person said, “This place is very clean and tidy. The cleaners are excellent.” These comments reflected people's confidence in the standards of hygiene maintained within the home.

Staff had access to appropriate personal protective equipment (PPE) and were able to obtain this when required. Suitable cleaning products and equipment were readily available to support effective infection prevention and control practices. Staff understood their responsibilities in maintaining a clean and safe environment and reducing the risk of cross-contamination.

The kitchen was organised and operated in a way to promote food safety. Food was stored appropriately and items were labelled and dated when opened to ensure they remained safe for consumption. These measures helped to protect people from the risks associated with poor food hygiene and demonstrated good infection prevention and control practices throughout the service.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Medicines were stored securely, administered safely by competent staff and reviewed regularly to ensure they remained appropriate and effective. Staff took a person-centred approach, working closely with people, their families and healthcare professionals to achieve the best possible outcomes.

People received their medicines from trained and competent staff who followed safe medicines management procedures. Staff responsible for administering medicines had received appropriate training and their competency was assessed regularly to ensure their practice remained safe and in line with current guidance. Staff demonstrated a good understanding of people's medicines and the support they required.

Medicines were stored securely, administered appropriately and reviewed regularly to ensure they remained suitable and effective in meeting people's needs. Staff took a person-centred approach and worked closely with people, their relatives and healthcare professionals to achieve positive outcomes. One person shared, “I don't worry about my tablets because the girls get them for me. I used to forget and that wasn't good for me. I feel better now because I take them regularly."

During our assessment, we identified some areas where medicines systems could be strengthened. For example, we found some medicines had not been included within regular audit processes and some 'when required' (PRN) medicines did not contain sufficiently detailed guidance to support consistent administration. We discussed these findings with the provider, who demonstrated awareness of some of the concerns identified and had already commenced action to improve PRN protocols. Immediate action was taken to address the areas we highlighted.