We carried out a review of the data available to us about Acacia Lodge on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Acacia Lodge, you can give feedback on this service.
We found the following examples of good practice.
¿ Information was on display at the entrance to the service. This ensured visitors followed guidance and procedures to ensure compliance with infection prevention and control.
¿ People were supported to keep in touch with their friends and family via alternative means during lockdown when visits were not permitted. This included video and telephone calls.
¿ Personal protective equipment (PPE) such as aprons, gloves and masks were seen to be available throughout the service. We saw PPE was worn by staff in line with current government guidance.
¿ Staff and people living at the service continued to receive a COVID-19 test as part of the Government's whole home testing scheme. This enabled the provider to respond swiftly should anyone receive a positive test result.
¿ All staff were supported to complete individual risk assessments; this included consideration of staff from black, Asian and minority ethnic groups, pregnant staff or those who had existing health conditions. This meant that supportive measures could be put in place to ensure they were supported effectively.
¿ In order to reduce the risk of infection spread the staff room was locked when not in use and breaks were staggered. This meant that social distancing could be maintained.
Further information is in the detailed findings below.
About the service
Acacia is a care home and was registered to provide accommodation for up to 18 people. People who used the service had physical health needs and/or enduring mental health needs. At the time of our inspection 17 people were using the service.
The accommodation was on one level. There were bedrooms with ensuite facilities, communal bathrooms and social spaces which included a lounge, dining area and activity space. There was also a secure garden with a separate smoking area.
People’s experience of using this service and what we found
People were supported by staff who understood how to protect people from the risk of harm or infection. Information was shared with people, so they knew how to access support when needed. Risks were identified and measures put in place following the least restrictive practice. There was enough staff to support people’s needs and this arrangement was flexible to support changes in care needs. Medicine was managed safety. People received regular reviews and any changes were recorded and monitored. Lessons were learnt when things went wrong and shared with staff.
Staff had received training for their roles and continued development was promoted. Information and best practice was shared with staff and training supporting this area to improve staff knowledge. People enjoyed nutritional meals and were part of the decision making. Health care was monitored, and relationships had been established with professionals who provided support and guidance. The home was on one level and supported people’s mobility and any personal reflections for their own spaces.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. Relationships had been established with staff and they supported people to make choices or follow their goals. There was an understanding about peoples cultural or equality needs. Privacy and choices were respected, and people liked the security of the CCTV.
The care plans were detailed and included people’s life history and current choices and preferences. They were regularly reviewed and shared with staff to support the current care needs required. When people expressed behaviours which were challenging, staff had completed a planned approach with professionals to support the best approach for that person.
Communication was shared with people through written information and on the notice boards. There was an opportunity to engage in activities to support people’s interests and hobbies, and these were discussed and agreed.
There was an open culture within the home and people and relatives felt able to raise any concerns. Staff felt listened to and were able to share ideas and any changes were supported. The home was well managed by a supportive governance system which reflected provider oversight and ongoing learning and improvement. Audits were completed and supported this approach.
People’s views were sought from meetings and questionnaires and their suggestions responded to and shared through written information. Partnerships had been established with health and social care professionals to support the people who use the service and the staff in their role.
The registered manager understood their role and sent us notifications of incidents and displayed their current rating at the home and on the website.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection: The last rating for this service was Good (published 30 August 2017).
Why we inspected
This was a planned inspection based on the previous rating.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
This inspection visit was unannounced and took place on 10 August 2017. This was the provider’s first inspection since their registration with us in July 2016. The service was registered to provide accommodation for up to 16 people. People who used the service had physical health needs and/or enduring mental health needs. At the time of our inspection 14 people were using the service.
There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
The provider had completed a comprehensive range of audits in relation to all aspects of the home and service. They had reflected them in an improvement plan and these were actioned to continue to drive improvements in relation to the home and the service provided. Staff felt supported and they received supervision and the opportunity to expand their roles through working in a team. People’s views had been obtained and felt that their requests or suggestions had been responded to.
The home had systems in place to maintain people’s safety. Staff understood the importance of reporting any concerns to avoid people coming to any harm. Risk assessments had been completed on an individual basis. These reflect the risks and provided options or guidance to manage these. People received their medicine as required in a safe way and referrals were made to a range of health care professionals when required to support people’s wellbeing.
Some people using the service did not have the capacity to make their own decisions; they had been supported to ensure decisions were made in their best interest. When required some people received the support of an advocate or guardianship to support more complexed decisions. There were sufficient staff to support people’s needs and the provider had increased the staffing to support areas of identified needs to reduce the risks to people. When staff were recruited checks were completed to ensure they were safe to work with people who used the service. Staff received an induction which provided them with training and the guidance they needed. Further training was provided to support the staff’s role.
People enjoyed the food and had the opportunity to make choices about the meals they received. The staff treated people with respect and people told us the staff made time for them when they needed the support. People knew how to raise a complaint and any received had been responded to. People had the opportunity to contribute to their care plans and changes had been implemented following their comments or requests.
People felt the staff offered them support and guidance. They had established positive relationships with the staff and felt their dignity and opinions were respected. Stimulation and interests were promoted, and further developments were being planned to consider therapies to expand opportunities for people. People felt able to personalise their space and make choices about their day.
The manager understood their responsibility of registration with us and notified us of important events that occurred at the service; this meant we could check appropriate action had been taken.