21 January 2022
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.
As part of CQC’s response to the COVID-19 pandemic we are looking at how services manage infection control and visiting arrangements. This was a targeted inspection looking at the infection prevention and control measures the provider had in place. We also asked the provider about any staffing pressures the service was experiencing and whether this was having an impact on the service.
This inspection took place on 5 January 2022 and was announced. We gave the service 24 hours’ notice of the inspection.
21 January 2022
About the service
Acacia Lodge Care Home is a nursing home providing personal and nursing care for up to 40 people with dementia and physical disabilities. There were 22 people receiving care at the time of the inspection.
People’s experience of using this service and what we found
Records required improvement. We found gaps in the recording of peoples care needs such as, repositioning, fluid management and safety checks.
Medicine management required improvement. We found concerns relating to the information and recording of medicines.
Health and safety checks were in place however, we found records of low water temperatures which increased the risk of Legionnaires disease.
People were not always safeguarded from the risk of abuse. Unexplained bruises had not always been investigated.
The provider and registered manager lacked oversight of the service. Audits completed did not identify the issues found on inspection.
Staff told us they did not always feel supported by the registered manager.
Staffing levels required reviewing. Staff rotas showed there was not always a consistent number of staff for each shift.
People were protected against infection. Staff wore appropriate personal protective equipment [PPE] and the home appeared clean.
People, staff and relatives were encouraged to feedback on the service. The registered manager and staff supported communication between people and their families throughout the pandemic.
Staff demonstrated that they knew people well including their likes, dislikes and personal preferences.
Rating at last inspection
The last rating for this service was good (12 October 2018).
Why we inspected
We received concerns in relation to safeguarding and staffing. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.
We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.
The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Acacia Lodge Care Home on our website at www.cqc.org.uk.
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service.
We have identified breaches in relation to safe care and treatment and management oversight at this inspection.
Please see the action we have told the provider to take at the end of this report.
We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.