Acer Court 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 changed to 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 safe care and treatment and safe and effective staffing.

This service scored 41 (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 promote a proactive and positive culture of safety based on openness, honesty and learning. Lessons were not always learnt to continually identify and embed good practice.

While staff understood how to record and report incidents and concerns, some told us they did not feel their concerns were always listened to or acted upon. This had the potential to discourage open reporting and limit opportunities for learning and improvement.

People using the service and those important to them were not always confident that concerns they raised would be addressed. As a result, the provider could not be assured that all feedback was being used effectively to improve the quality and safety of care.

The provider recognised improvements were needed and told us they had been working with staff at all levels to strengthen relationships and improve the culture within the home. However, these actions had not yet fully embedded an open and learning-focused culture where concerns consistently resulted in positive change.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Although the provider worked with people to transition safely between services, management of risks was not always conducted safely when people first moved to the home. For example, a person had recently moved into the home and was known to become emotionally unsettled during periods of change. Appropriate risk management plans were not in place when they were admitted, and an incident subsequently occurred. This meant the person's needs were not fully understood and planned for, placing them at increased risk during an important period of transition.

Following the incident, the provider reviewed the circumstances and implemented additional support measures to reduce the risk of reoccurrence.

People told us they were visited at home by the provider to carry out a preadmission assessment which they valued.

Healthcare professionals felt the service worked well with them through periods of transition and change.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

Generally, people told us they felt safe living in the home. However, a number of people told us of incidents where other people living at the home entered their room uninvited, which upset them.

One person told us, “I’d say it’s safe, but people wander in and out your room. It’s every week. I’ve come back to my room and find them in there and tell them to go.” However, not all people or relatives felt safe. One relative told us they did not feel their loved one was safe. They had raised their concerns with the provider and were awaiting a response.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through 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 managed DoLS within the service. The service had requested DoLS authorisations where appropriate but did not clearly state any conditions included in these in care plans. This meant we were not assured DoLS conditions were followed and met.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People told us they were not always included in care planning and risk assessment processes. As a result, opportunities to understand people's views, preferences, and desired outcomes when managing risks were sometimes missed. This meant risk management approaches were not always developed in partnership with people or reflective of what was important to them.

People and their relatives described occasions when they felt unsafe due to other residents entering their bedrooms without permission. Some people affected by this did not have access to call bells or other means of summoning support when they felt distressed or required assistance. This increased the risk that people could feel vulnerable and unsupported, and appropriate measures had not always been put in place to mitigate these concerns effectively.

We observed occasions where people's expressed wishes were not respected. For example, one person repeatedly requested to go to their bedroom; however, staff directed them to remain in the communal lounge areas and did not support their preferred choice. The person's views and preferences were not acted upon, which placed them at risk of institutional practices where people had limited control over their environment and routines.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

During the assessment, we found several environmental hazards that had not been identified or addressed. Storage rooms and cupboards containing pipework were left unlocked, creating unnecessary risks to people living in the home. Bins were poorly maintained, with some lacking bin liners and others having broken lids. This presented a risk of poor hygiene and unsafe waste management.

Hazards within people's bedrooms had not been appropriately managed. We observed wires and extension leads across bedroom floors, posing a significant trip hazard to people. Topical creams were also found stored in bedrooms without appropriate safeguards, creating a risk of misuse or accidental ingestion.

Staff did not always identify or respond to risks associated with people's day-to-day safety. During the assessment, we observed people walking around the home without footwear, wearing inappropriate footwear, and in some cases wearing footwear on the wrong feet. Staff had not recognised or addressed these concerns, despite the increased risk of slips, trips and falls.

We also observed people walking purposefully into other people's bedrooms without staff intervention. This demonstrated a lack of oversight and risk management to protect people's privacy, dignity and safety. We raised these concerns with the provider during the assessment who told us they would take action.

The home had well maintained garden space, including greenhouses which were used by people living at the service. However, outside the dining room door which led to the garden space was a bucket filled with discarded cigarettes, tissues and packaging. This posed a fire risk and placed people, staff and visitors at risk of harm.

The provider did not ensure there were enough suitably qualified, skilled and experienced staff to meet people's needs safely. Staffing levels were insufficient, and people were exposed to avoidable risks due to a lack of supervision and support.

During the assessment, communal areas were frequently left unstaffed, and people were unable to summon assistance if required. Inspectors had to intervene on occasions to reduce immediate risks to people's safety. We also observed people moving around the home without their required walking aids, increasing the risk of falls and injury.

People, relatives and staff consistently told us there were not enough staff. Comments included, “No there’s not enough all the time” and “It’s changed for the worst.” A relative told us, “They work hard and seem to cope, but I sometimes wonder at what cost.” These concerns reflected the impact staffing shortages were having on people's experiences and care.

Staff described working under significant pressure and told us staffing levels affected their ability to meet people's needs safely. Some staff reported becoming visibly distressed at work due to the demands placed upon them. Staff also told us they required further training to support people living with dementia and those experiencing emotional distress, and not all felt confident in these areas.

The provider had failed to ensure sufficient staffing levels and an appropriately skilled workforce. As a result, people were at risk of receiving unsafe care, experiencing delays in support, and having their needs unmet.

The concerns were raised with the provider who took action to review and increase staffing in certain areas of the home at certain times of day

The provider did not have effective systems in place to assess, monitor and manage the risk of infection. Infection prevention and control (IPC) practices were poor and did not ensure people were protected from the risk of avoidable harm. The provider had failed to identify and address environmental concerns that increased the risk of infection spreading within the home.

During the inspection, we observed poor standards of cleanliness throughout the service. There was a build-up of dirt in a number of areas, and surfaces were visibly food-stained and sticky. Some areas of the home had strong unpleasant odours, indicating cleaning practices were not effective in maintaining a clean and hygienic environment.

Equipment used to support people's care was not always clean or fit for purpose. Pressure cushions and sensor mats were stained and unhygienic, and we found dried faeces in bathroom areas. Some mattresses were heavily soiled and torn, meaning they could not be cleaned effectively or decontaminated. This increased the risk of bacteria accumulating and infections spreading.

The provider had not ensured waste and personal protective equipment (PPE) were disposed of appropriately. We observed used PPE which had not been discarded safely, creating an increased risk of cross-contamination and poor infection control practices.

The staff room was accessible to people living in the home and was found to be unclean. An overflowing bin and food debris on the floor further demonstrated a lack of effective housekeeping and infection control measures. These findings showed that standards of hygiene were not consistently maintained across the service.

The concerns were raised with the provider on the day of the assessment. They took immediate action to address some of the concerns and assured us they would continue to review and make changes to improve IPC within the home.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

During the assessment, we found medicines trolleys left unlocked in communal areas. This increased the risk of people accessing medicines that had not been prescribed for them and demonstrated poor medicines security practices.

Topical creams were found stored in people's bedrooms without appropriate oversight. Some did not have an opening date recorded, while others had exceeded their recommended period of use. This meant staff could not be assured that medicines remained safe and effective for use.

We reviewed medicine administration records and found that time-critical medicines, including those prescribed for Parkinson's disease, were not always administered at the prescribed times. Delays in administering these medicines can significantly affect symptom control and place people at risk of deterioration in their health and wellbeing.

The management of 'when required' (PRN) medicines was also inconsistent. Protocols were not always in place to guide staff on when these medicines should be given, the signs and symptoms they were intended to treat, or the expected outcome following administration. The absence of clear guidance increased the risk of medicines being administered inconsistently or inappropriately.

These concerns demonstrated a failure to ensure medicines were managed safely and effectively. As a result, people were exposed to risks associated with poor medicines management, including incorrect administration, delayed treatment and avoidable harm.

We found thickener powder stored safely in locked boxes. Staff had access to this, but protected people from accessing prescribed medicines not required by them.