Acer House Care Home

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 good. At this assessment,the rating has remained good.This meant people were safe and protected from avoidable harm.

This service scored 72 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice.

Accidents and incidents were recorded by staff and reviewed by the registered manager. The registered manager demonstrated a tracker that provided an overview of the person involved, the time of day, the location of the accident, and a description of what had happened, along with the actions taken to reduce future risks.Staff were confident in explaining how they support people with mobilisation when required.

However,although systems were in place for staff to record accidents and incidents, and the registered manager maintained an overview through a tracker, the provider did not always demonstrate that lessons were consistently learnt from these events. Records showed that while individual incidents were documented, there was limited evidence of robust analysis to identify emerging patterns or repeated themes.

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.

The service used clear systems to ensure safe and well planned admissions, transfers and changes in need. The registered manager carried out preadmission assessments, involved relatives and professionals, and used this information to plan smooth transitions into the home. A relative said,“Mum is frail but has all her faculties so we (family) went to visit the home initially and then the manager saw mum in hospital before she was discharged and asked lots of questions.”When peoples’ needs changed, senior staff and the registered manager reviewed risks promptly, updated care plans and arranged specialist support or equipment to maintain safety and continuity.

During emergency hospital admissions, staff accompaniedpeople,shared essential information with hospital teams and ensuredpeoplewere reassessed before returning to the home. Leaders monitored all transitions, to strengthen pathways.Onerelative said,“[Person]went in there (home) with severelymphoedema, but I was told they had acarerwho knew how to deal with it. That has been amazinglysuccessful,and swelling is vastly reducednow.”Consistentcommunication and guidance from managers supported coordinated, safe care throughout eachpeople’s stay.

External healthcare professionals expressed confidence in the provider’s processes to ensure good transitions between healthcare providers. One healthcare professional told us, “The manageris on top of things. We work well with her. Sheis a major part of organising and hosting thecare hubmeetings. Sheis good at following through on instructions.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staffconcentrated 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, which helped prevent issues from escalating.

The registered manager and staff understood different types of abuse and explained how they would report concerns to leaders.Stafffelt confident the provider would act quickly.Peoples and relatives told us the home felt safe. One relative said,“The front door is always locked and there isalways someone at the receptiondesk keeping an eye out to ensureonly authorised people can come in.”

Staff gave examples of actions they had taken to safeguardpeoples. Whenapersonshowed unexplained bruising, staff reported it immediately, arranged a GP visit and reviewed the person’s moving and handling plan. Following repeated falls, staff increased observation checks, carried out a falls review, added sensor equipment and worked with the GP to review medication. These actions reduced risks and improved safety outcomes for those individuals.Safeguarding concerns, accidents and incidents were documented consistently. A health and social care professional told us,“They do reportand notify us of incidentsand any safeguarding concerns”.

People can only bedeprivedof their liberty to receive care and treatment with appropriatelegal authority.In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managedDoLSwithin the service.Sixpeople were underDoLS, and applicationshad been made for27people. We found the service was working within the principles of the Mental Capacity Act (MCA) and if needed, appropriate legal authorisations were in place to deprive a person of their liberty. These were kept under review and monitored. People’s capacity and the Deprivation of Liberty Safeguards (DoLS) in place were included in people’s care plans, including what theDoLSmeant when supporting people. Where people requiredsupport to make decisions this was documented, including how decisions were made in people’s best interests.

The service followed the Mental Capacity Act 2005. Staff assessed capacity, supportedpeopleto make decisions and applied restrictions lawfully when required and inpeoples’ best interests. Staffhadcompleted safeguarding,MCA andDoLStraining, which helped them respond appropriately to concerns and protect people from harm.

The provider worked with people to understand and manage risks 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.

Staff involved people in understanding and managing their own risks. They provided safe, supportive care that helped people remain independent and continue activities that were important to them. The service used clear systems to assess individual and homewide risks and responded quickly when needs changed.

The registered manager and staff worked proactively to reduce falls. They reviewed incidents in monthly governance meetings and acted on learning. Staff worked with relevant health professionals to assess mobility needs and recommend suitable walking aids and equipment. They also monitored people closely and stayed available to help. One person said,“They are always near when I stand up, if I have a wobble,they are ready to steady me”.

People’s care records were accurate and up to date, giving staff clear guidance on how to manage specific risks. Staff knew where to access risk related information, such as eating and drinking support plans for people at risk of choking and used this to keep them safe.

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

Staff maintained a safe, clean and well organised environment that supportedpeoples’ comfort, mobility and independence. Theyidentifiedhazards quickly, reported issues without delay andensuredrepairs were completed promptly to reduce risk.

Theservicehad maintenance staffwhocarried out regular checks on the building, equipment andfire safety systems. These checks helped staff identify environmental risks early and maintain a safeand well maintained home. Staff took day today actionssuch as keeping walkways clear, removing obstacles and using wet floor signsto prevent slips, trips and falls.

Peopleand relatives consistently told us the home felt safe, accessible and well cared for. They described the building as clean, secure and easy tonavigate, which helpedpeoples move around with confidence.One relative said,“Iam aware of 2 deep cleans they have done in her room,it’salways cleanandclutter free”. Apersonsaid, “Staff are always cleaning, nothing is out ofplace”.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision anddevelopment. They worked together well to provide safe care that met people’s individual needs.

We received mixed reviews on the level of staffing. Some relatives felt there were less staff during the weekend. Records we reviewed indicated staffing levels met peoples’ needs. Senior management described how they adjusted rotas when support requirements changed. The registered manager said,“We increase cover for people needing more mobility support and allocate extra staff during busy periods, such as when someone experienced repeated falls”.

Robust recruitment checks were completed,including identity verification,Disclosure and Barring Service (DBS)clearance, reference checks, and confirmation of any employment gaps.This ensured staff were safe to work with people.

Staff had the training and competence to deliver safe care. They completed mandatory courses including safeguarding, moving and handling, medication administration and dementia awareness. Staff received additional training when peoples’ needs changed, such as wound care and catheter care to reduce the likelihood of infections.One staff said, “We are always training, they check we are giving medicine correctly.”Senior management monitored training through a live training matrix, reviewed compliance during supervision, and scheduled refresher sessions when staff were due or overdue. This ensured the whole team maintained current skills.

Supervision practices further strengthened safe staffing.Senior management held regular one to one meetings that covered peoples’ risks, staff wellbeing, training updates and reflective discussions following incidents. They completed competency checks, such as observing moving and handling and medication administration, to ensure staff applied learning correctly. Staff said“The checks are good; they help me do my work well. I feel confident and clear about what I need to do.”

People received support from staff who received training and supervision. This ensured people received timely support and experienced consistent care.

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 completed infection prevention and control training and confirmed they had access to personal protective equipment (PPE). One staff member said, “I always wear gloves and apron before providing personal care or cleaning the bathroom.”One person confirmed, “They always wear gloves even when they are giving me medicine”.Care plans included clear infection control guidance, such as how to clean equipment safely.

The service remained clean, well maintained, and free from odours. People and relatives said staff used PPE appropriately. A relative told us,“It always smells nice“Yes, they always wear their gloves and aprons.”

Staff said managers carried out spot checks to ensure correct PPE use. They reported following PPE guidance consistently and having sufficient stock.The provider’s infection prevention and control policy reflected national guidance. During a recent respiratory outbreak at the home, staff and leaders explained the additional measures they implemented to manage it safely.

The provider ensured medicines and treatments were safe and aligned with people’s needs, capacities and preferences. Staff involved people in planning their care, including when changes occurred. Medicines policies supported safe administration, and staff followed clear protocols for the use of PRN (‘as required’) medicines.

The management team completed regular medicines audits and implemented action plans when they identified shortfalls.During the assessment,we observed staff using electronic medication administration record (eMAR) system and giving people their medicine. Staff checked the name of the medicine and the name of the person they were administering to. This ensured people received the correct medicine in the right way. We observed medicine kept in a secure storage area.

Staff completed medicines training and were assessed as competent before administering medicines. One staff member told us,“The manager and deputy manager carry out competence checks and work closely alongside us. This means they can support us straight away and help correct any mistakes as they happen”.

People and relatives were generally satisfied with medicines support. Most people said they received their medicines as prescribed. One person said,“There have never been any medical issues that I have been told about and they normally communicate well.”A few felt the medicine round was not always on time; however, records we reviewed showed medicines were given on time. Any delays were documented with clear explanations, and no one came to harm.