CQC report explained · a residential care home
What the CQC found at 18 Acorn Avenue
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Staffing, risk management, infection control and medicines systems were generally effective, although inspectors recommended action on medicine storage temperatures.
- Effective?
- Good
- This question was not inspected in this report. The report says ratings for key questions not inspected were carried over from the previous inspection.
- Caring?
- Good
- This question was not inspected in this report. The report says ratings for key questions not inspected were carried over from the previous inspection.
- Responsive?
- Good
- This question was not inspected in this report. The report says ratings for key questions not inspected were carried over from the previous inspection.
- Well-led?
- Good
- The home had consistent management, better staffing and effective checks on quality and safety. Relatives said communication from the manager needed to improve.
What inspectors found, July 2023
Rated Good; inspectors found kind, safe care and improvements, but medicines storage and family communication needed attention.
The home provides accommodation and personal care for up to three people with a learning disability or who are autistic. There were two people living there at the inspection. This was an unannounced, focused inspection. One inspector visited the home and also spoke with relatives by telephone. They reviewed care, recruitment, training and management records.
Inspectors found enough trained staff to meet people's needs, including one-to-one support. People were treated kindly, supported to make choices and helped to take part in activities and community life. The home was clean, refurbished and managed risks well. Medicines were generally administered and recorded safely, but the medicine cabinet was sometimes above the recommended temperature.
The overall rating was Good. Safe and Well-led were both rated Good. The previous overall rating was Requires Improvement, and inspectors found improvements in staffing, management, maintenance and oversight. This report only inspected Safe and Well-led, so ratings for the other questions were carried over from the previous inspection.
Kind and personal care
Staff showed genuine interest in people's wellbeing. People appeared comfortable, happy and engaged, and staff supported their individual choices and communication needs.
“They were kind, caring and nurturing and as a result we saw people were at ease, happy, engaged and stimulated.” from the report
Enough suitable staff
Inspectors found staffing numbers and skills matched people's needs, including support for activities and holidays. The home reported it was fully staffed and using little agency staff.
“The numbers and skills of staff matched the needs of people using the service, including for 1-to-1 support to enable people to go on holiday” from the report
Improved environment
The home had been refurbished and maintenance processes had improved. Inspectors found effective infection prevention and control measures and a clean, hygienic environment.
“The premises had also been refurbished throughout, enabling staff to keep the premises clean and hygienic.” from the report
Better management oversight
The home used audits, improvement plans and quality meetings to identify problems, monitor changes and share lessons from incidents.
“Effective governance arrangements were in place to assess the quality and safety of the service.” from the report
Medicine cabinet temperature
needs fixingThe medicine cabinet was sometimes above the recommended 25°C, especially in hot weather. Inspectors made a recommendation for the home to review its medicine storage arrangements.
“However, temperature checks of the medicine's cabinet in the office, showed these exceeded the recommend 25°C some days, especially in the hotter weather.” from the report
Communication with relatives
needs fixingSome relatives said the manager did not keep them sufficiently informed about their family member. The provider said it was considering regular family forums.
“The manager doesn't communicate with me, which makes me feel left out the loop,” from the report
- 01How are you now checking and recording the medicine cabinet temperature, particularly during hot weather?
- 02What action have you taken following the recommendation about safe medicine storage?
- 03How will you keep relatives updated about their family member's care and wellbeing?
- 04Have regular family forums started, and how can relatives take part?
- 05How often do you use agency staff now, and how do you maintain consistency when regular staff are absent?
This was a focused inspection of Safe and Well-led; the ratings for Effective, Caring and Responsive were not newly inspected and were carried over from the previous inspection. This explanation was written from the published report of 1 July 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, February 2022
18 Acorn Avenue was rated Requires Improvement; care was kind and personalised, but safety systems and wider management needed improvement.
This was the home's first inspection after its new registration. Two inspectors visited without warning on 24 November, 29 November and 13 December 2021. They met the three people living there, contacted relatives and professionals, spoke with staff and managers, and checked care, medicine, recruitment and management records.
The home was rated Good for Effective, Caring and Responsive. Inspectors found kind care, good support for communication and independence, enough staff, personalised activities and suitable support with health, food and medicines.
The home was rated Requires Improvement for Safe and Well-led. A safeguarding investigation did not fully consider people's emotional and communication needs. The property had maintenance, storage and infection-control problems. Frequent management changes meant improvements were not always completed or maintained.
This overall rating means the service was not consistently meeting the standard expected. Inspectors said there was an increased risk that people could be harmed, although the registered manager and staff were taking action and the provider had agreed to improve oversight.
Kind and respectful care
Inspectors saw staff providing patient, calm and compassionate support. Staff respected people's privacy, dignity and individual sensory needs.
“People received kind and compassionate care. Staff protected and respected people's privacy and dignity.” from the report
Independence and choice
Staff focused on what people could do and supported them to make choices, develop skills and take part in activities in the community.
“Staff focused on people's strengths and promoted their independence. They supported people to take part in activities and pursue their interests in their local area.” from the report
Staff understood people's needs
Staff knew people well, including their communication needs and signs of distress. Agency staff were also given time to learn about the people they supported.
“Throughout our visit we observed staff had good awareness, skills and understanding of individual communication needs.” from the report
Personalised health and medicine support
People received support with medicines, eating, health appointments and specific risks such as choking. Staff followed relevant guidance and supported people to be as independent as possible.
“People were supported by staff who followed systems and processes to prescribe, administer, record and store medicines safely.” from the report
Activities and relationships
People were supported to continue their interests, try new things and stay in touch with family and friends, including during the pandemic.
“People were supported to participate in their chosen social and leisure interests on a regular basis.” from the report
Safeguarding investigation
seriousA serious safeguarding concern had been referred to the local authority, but the provider's investigation did not fully consider people's emotional and communication needs or the effect on their wellbeing. Inspectors said this increased the risk that people could be harmed.
“The investigation carried out by the provider demonstrated a lack of knowledge of the emotional and communication needs of the people at the service, and the impact the safeguarding had on their wellbeing.” from the report
Condition of the property
needs fixingDelays to maintenance and upgrading made it harder to keep the property clean and reduce infection risks. Storage was also limited, and some work, including the laundry room refurbishment, was still outstanding.
“Delays in maintenance and upgrading of the property meant it was challenging for staff to minimise the risk of infection.” from the report
Infection-control procedures
needs fixingSome infection-control arrangements were not always followed. Inspectors were not asked for evidence of vaccination status before entering, and one example involved gloves being put in a general waste bin.
“There were systems in place to prevent visitors from catching and spreading infections, however these were not always followed.” from the report
Frequent management changes
needs fixingHigh turnover at management level and wider organisational changes affected staff morale and meant improvements were not always sustained. The provider was not always visible or timely in dealing with outstanding tasks.
“High turnover at all levels of management meant change was not consistently implemented and improvements were not always sustained.” from the report
- 01What actions have been completed to address the safeguarding investigation concerns, and how will people's communication and emotional needs be considered if another concern arises?
- 02Which maintenance and upgrading jobs are still outstanding, including the laundry room refurbishment, and when will they be finished?
- 03How are infection-control checks carried out now, including visitor vaccination checks and clinical waste disposal?
- 04How will the provider ensure the home has consistent management cover and effective oversight when the registered manager is absent?
- 05Have the end-of-life care plans been completed and reviewed with each person's representatives?
This was an unannounced first inspection of the newly registered care home and covered all five CQC questions, including the premises and the care provided. This explanation was written from the published report of 11 February 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of 18 Acorn Avenue
2 rated inspections over a year: the service has improved, from Requires improvement to Good.
- July 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2022Requires improvementSafe: Requires improvementWell-led: Requires improvement
- March 2021Inspected but not ratedSafe: Inspected but not rated
- July 2020
Registered with the Care Quality Commission on 23 July 2020.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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