Acacia 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.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good.

This meant people were safe and protected from avoidable harm.

The provider was previously in breach of the legal regulations relating to safe care and treatment and staffing. Improvements were found at this assessment and the provider was no longer in breach of these regulations.

Leaders had strengthened systems for managing risks, medicines and people's changing needs and embedded them into practice.

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.

The registered manager maintained clear records of incidents and complaints and investigated these through to completion. The registered manager documented learning outcomes, actions and service improvements. The registered manager communicated these to staff and reviewed them through governance systems and team meetings. We saw an example where the registered manager sought additional assurances, beyond statutory requirements, when investigating a complaint concerning a person's care and wellbeing. This included obtaining additional information to fully understand the circumstances of the incident and the support the person had received. As a result, the registered manager identified learning for the service, shared this with staff and reviewed care records and working practices to help reduce the likelihood of similar concerns arising in future. This demonstrated a proactive approach to learning and continuous improvement.

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 provider worked closely with healthcare professionals to ensure people's changing needs were assessed and responded to appropriately. We saw evidence of referrals and involvement from a range of professionals including physiotherapists, GPs, occupational therapists (OT), dietitians and speech and language therapists. Staff reflected changes in people's needs and professional recommendations in the support people received, helping to maintain continuity of care. Staff used daily records, care plan evaluations and handovers to share information and ensure people received consistent support.

A relative told us "[The person] is having physiotherapy at the moment. Seen by OT," demonstrating people's access to specialist services when their needs changed.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

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

Risk assessments and care plans reflected people's individual circumstances and staff updated these when needs changed. We saw examples of people being supported by staff to maintain relationships, go out and about and make choices about their care whilst risks were managed safely together. The provider worked with healthcare professionals and others involved in people's care to help ensure people could do the things that mattered to them in the safest way possible.

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

During our visit, we observed a clean, well maintained environment, suitable for the people living there. Equipment used to support people, including moving and handling equipment, was available and reflected people's assessed needs. Environmental checks and audits provided leaders with oversight of health and safety matters and helped them ensure identified concerns were addressed.

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 registered manager reviewed a staffing levels calculator to ensure appropriate support ratios. The provider had recently recruited an additional administrator and an activities coordinator. The staff used handovers and electronic communication to share information effectively. The registered manager gave staff regular supervision and supported their development. We saw team meeting records which showed discussions around training, communication and changes in people’s needs. These measures helped ensure staff had the skills, support and information required to meet people's needs safely and effectively. Whilst 1 relative felt staffing levels could be improved at times, they acknowledged action was being taken and told us, "I think they are trying to sort that out because I've seen a number of new faces."

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.

We reviewed infection prevention and control audits and associated action plans, which showed leaders maintained oversight of environmental cleanliness, hand hygiene resources and cleaning arrangements.

Records demonstrated leaders routinely monitored cleaning schedules and personal protective equipment availability, helping to ensure infection prevention and control arrangements remained effective.

The registered manager told us the service had recently achieved a 5-star food hygiene rating following an inspection of the kitchen. We also saw the service employed dedicated chefs, which supported oversight of food preparation and kitchen standards.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

The registered manager conducted weekly and monthly medication audits. We saw the registered manager had used audit findings to identify areas requiring improvement and monitor actions through to completion.

The registered manager assessed staff’s competency at medicines administration and conducted 4 spot checks per week on medicines processes to reduce the likelihood of errors. Staff monitored stock and recorded medicines use accurately on medicines administration record charts.

The registered manager completed mental capacity assessments with people regarding medicines administration with best interests decisions recorded when needed. The provider had fully documented all instances where covert medicines administration was required. The provider had consulted families, GPs and pharmacists appropriately and had detailed instructions and managerial oversight for PRN (taken when required) medicines. The provider had recorded guidance regarding food interactions and whether medicines can be crushed.