Four Acres

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 69 (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 manager explained how they listened to people, made themselves available and worked with staff so they understood the service. Staff we spoke with said this was an improvement in managerial practice. Staff said they could approach the manager, raise any concerns and they felt confident things would change.

The manager told us they had daily ‘flash’ meetings where, if needed, they shared any lessons learnt. Staff use these meetings to consider if any learning could be taken in respect of incidents and accidents and if improvements could be made in meeting people’s clinical needs.

Regular reviews of incidents, accidents and clinical tasks were made through monthly checks. The manager told us through some of those reviews, improvements were made. For example, 1 person’s incidents and falls had decreased following a review of their medicines.

The regional operations director told us they shared lessons from other inspections to improve practice across the provider’s homes. One example was learning to improve knowledge around modified diets and the importance for staff to follow the International Dysphagia Diet Standardisation Initiative (IDDSI) for those people at risk of choking.

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.

People were supported to access healthcare services when required. People’s individual records showed staff worked with a range of health professionals including speech and language therapists, dietitians, district and frailty nurses and mental health teams. Written feedback from a health professional showed people received the support they needed. This feedback said the service had a, “Positive culture of learning and willingness to understand their residents and to support them.”

Staff understood other health professionals required key information when people transferred between services, such as from the home to hospital, so people promptly got the care they needed. Staff told us a ‘hospital pack’ was extracted from their electronic care recording systems. This meant other professionals had immediate access to vital information when they began to care for people from the home, in emergency situations. If relatives were not available to support people to attend routine external health appointments, staff accompanied them to ensure continuity of care.

Senior staff understood people's needs and referrals were made promptly when concerns were identified. In examples we saw, people’s medicines were reviewed with other professionals which had a positive impact on their overall health and wellbeing. Regular checks monitored health outcomes such as people’s nutrition, skin integrity and deteriorating health. Staff reviewed people’s needs to ensure appropriate support was provided, as well as making timely referrals where needed. We identified some isolated examples where specialist guidance or equipment needed improved oversight for it to remain effective. For example, pressure relieving equipment and nutritional information for specified diets. The manager assured us our feedback would be acted upon, demonstrating a commitment to improving people's safety.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated 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.

People felt safe. Comments included, “It is safe and secure here, I feel 100% safe” and “The people here make me feel safe.” One person told us they felt safe and comfortable living at Four Acres because, “I have made friends.” A relative shared a positive example with us, saying, “I’ve got no concerns around [Person’s] safety. As soon as they moved in, staff put the sensor mat in, they came out and made sure [Person] had got all the right stuff in their room.”

Staff were confident to report any concerns and if needed, staff knew which external agencies to inform. One staff member said, “I would call safeguarding and CQC.” Another staff member said, “We would speak to CTLs, [care team leaders], and managers. They would do something about it.” Records evidenced reporting of concerns to key agencies including local authorities and CQC. The manager knew what to report and they had submitted notifications to us when safeguarding incidents occurred. The manager said staff safeguarding training was regularly updated to ensure staff knew what to do to keep people safe.

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 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 managed DoLS within the service. Staff worked within the principles of the Mental Capacity Act 2005 (MCA). Where required, Deprivation of Liberty Safeguards (DoLS) authorisations were applied for to ensure people’s rights were protected. The manager maintained oversight of DoLS applications, any authorisations, and any associated conditions.

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.

People’s individual risks were identified, and robust plans were in place to manage, monitor, and reduce these risks. Assessments considered both people’s emotional needs, such as triggers which may lead to a person becoming anxious, and physical health risks, including skin integrity concerns and risks associated with falls and poor nutritional intake. Consideration to risk of injury was acted upon when people requested changes to the layout of their room. In 1 example, a relative requested shelves to be put above their family member’s bed, However, because the person had limited vision, staff had concerns regarding increased risk to the person. Staff worked together with the person and their relatives to agree layout changes to make it safer and more accessible to the person.

People’s care information contained guidance to inform staff how to manage people’s risks. This included how many staff to support a person, or what equipment they needed to manage risks of falling. People who had specific health conditions and who needed regular monitoring, were supported by district nurses. Information was shared with staff, and if staff had any concerns, they contacted district nurses to manage any escalating risk. Staff told us, daily meetings and handovers gave them up to date information about a person, so any new or emerging risks were known.

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

Some improvements were needed to the environment. Four Acres had communal areas and kitchenette areas for people to use to access drinks and snacks.People and relatives had access to a garden area. We saw plenty of seating opportunities and photographs to show people used this area. During our visit, there were 2 paddling pools which were full of water, but they were discoloured through ineffective cleaning. We mentioned this to the manager and both pools were emptied. However, no one deflated or stored them away, so they blew around the garden area presenting a potential trip hazard. They had been moved when we returned the following day.

More could be done to ensure potential environment risks to people were fully mitigated. This included ensuring all health and safety checks such as water temperatures, fire safety and infection control risks minimised the likelihood of equipment not operating safely. Fire safety checks were completed; however, the recording of what fire doors were checked and what those checks looked at, needed more detail. We saw water temperature checks were completed to ensure water temperatures were within safe temperature range. The provider only checked a small number of appliances, meaning it could take 12 months to ensure all temperatures were safe. In addition, we found 1 person who required a thickening agent to be added to their drinks. We saw this was left unsecured, meaning if ingested, it could cause a potential choke risk to people. The manager gave us assurances this would be addressed without delay.

The provider made sure there were enough qualified, skilled and experienced staff. The provider made sure staff received effective training and guidance, supervision and development. Staff told us they worked together well to provide safe care that met people’s individual needs.

Our observations showed there were enough staff to support people and for staff to spend time with people. However, people and relatives gave us mixed feedback. One person said, “It depends on how busy they are. Sometimes there is not enough staff, especially in the mornings when it is busy.” Another person said, “There is enough staff to meet my needs.”

Staff did not raise any concerns about staffing levels and although there were times of the day across the units when staff were busy, there was sufficient opportunity for staff to chat with people and to connect with them. One staff member said, “Staffing levels are good and we all help each other. There are eyes around, and we don’t want any falls on this team.”

The manager assessed staffing based on people’s needs and was confident it met assessed needs. The manager assured us staffing levels were regularly reviewed and the operations director said they had increased staff levels by 1 staff member following an increase in people’s needs. To give them confidence staffing levels were right, the manager visited the home during night shifts to ensure people’s needs were met across all shifts, and they monitored call bell response times.

The provider had effective processes to ensure all safe recruitment checks had been completed prior to staff starting with the service. Recruitment checks included staff identity checks, references and Disclosure and Barring Service (DBS) checks. DBS checks provide information including details about convictions and cautions held on the Police National Computer. This helps providers make safe recruitment decisions. Staff received mandatory and other relevant training appropriate to their roles.

The provider did not always assess and manage the risk of infection. They did not always detect and control the risk of it spreading promptly.

The main communal areas of the home such as lounges and corridors were clean. People said their bedrooms were clean. However, we found communal kitchenette areas in dining rooms were not always clean. Food debris existed in some cutlery trays, sinks were unclean, some food items were open and not labelled. We saw some clear plastic food containers were unclean and some refrigerators needed a deep clean to minimise any risks of cross infection. These levels of cleanliness had built up over time. In 1 kitchenette area we saw chocolates, glassware, and food items were left out or were inappropriately stored on top of cupboards, which could be a risk to some people. Daily cleaning checks and daily walkarounds were completed, however they had not identified these issues. We spoke with the manager who addressed this during our visit and who agreed to be more vigilant.

Housekeeping staff provided regular cleaning regimes throughout the home. Hand sanitisers were all working in key areas of the home, with paper towels and guidance to remind staff and visitors, of the importance of hand hygiene. Personal protective equipment (PPE) stations were positioned around the home, meaning staff had access to supplies. We observed staff using PPE as required. Catering staff ensured the inspector donned PPE appropriately prior to entering the kitchen.

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.

Records demonstrated people received their medicines as prescribed. Medicines administration records (MARs) were completed. We found no unexplained gaps or omissions identified in those records we saw.

Some people were prescribed medicines on an ‘as required’ basis (PRN). PRN protocols were completed to inform staff the reasons why and safe dose limits for each ‘as required’ medicine. Staff knew when people required their medicines and prioritised this, to ensure people had the medicines they needed to maintain their health and welfare.

Staff demonstrated confidence in administering medicines to people because they knew people well. Where people received their medicines via a patch applied directly to their skin, best practice guidelines were followed and application sites recorded on body maps. In 1 example, we discussed with a team leader the importance of applying a patch medicine to a different skin site, to best evidence medicine guidance was followed. We let the manager know so they could check staff practice was consistent.

Staff told us they had medicines training and their competency to administer medicines safely was checked. Medicines were stored safely and some medicines that required stricter controls, were managed safely.