CQC report explained · a residential care home
What the CQC found at Acacia Bank Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, February 2024
The Beeches Care Home is rated Inadequate and remains in special measures, with serious shortfalls in safety, staffing, care planning and management.
Inspectors visited without warning on 6 and 11 December 2023. They spoke with 11 people, one relative and 12 staff. They reviewed care, medicines, staffing and management records, and observed care.
The overall rating was Inadequate. Safe, effective, responsive and well-led were also Inadequate. Caring was rated Requires Improvement. Inspectors found risks were not managed reliably, medicines and food and fluid records were not always safe, staffing was not deployed effectively, and care plans did not consistently reflect people's needs and choices.
There were some positive findings. Infection prevention practices were safe, people were supported to access health professionals, complaints were recorded clearly, and staff said the new manager was supportive. However, the home had not made enough improvement since its previous Inadequate rating, published in June 2023.
The home remains in special measures. The CQC will request an action plan, work with the local authority and monitor progress. It expects to re-inspect within six months unless it proposes cancelling the provider's registration.
Infection control
Inspectors were assured that staff followed safe infection prevention practices. The home was clean and had enough protective equipment.
“The home was kept clean and hygienic and the provider had sufficient stocks of PPE.” from the report
Health professional support
People were supported to access health and care professionals, including GPs, district nurses and mental health teams.
“People's care records confirmed the involvement of other professionals in providing care such as the mental health team, community matrons, GPs and the speech and language therapy (SALT) team.” from the report
Improved staff support
Staff gave positive feedback about the new manager and said the atmosphere and support had improved.
“It's now changed to a happy team, we work as a team. The atmosphere is better.” from the report
Complaints handling
The manager had clear records of the complaint received and the actions and outcome.
“The manager had confirmed only 1 complaint had been received since they commenced as manager, and they kept clear and robust records of all actions taken and the outcome.” from the report
Unsafe medicines management
seriousInformation for variable medicine doses was sometimes missing. Cream records were incomplete, fire risks were not assessed, and the medicines fridge was outside safe temperature limits for 10 days without recorded action.
“Medicines were not being managed safely.” from the report
Risks and safety checks
seriousRepositioning records had gaps, some pressure-relieving equipment was missing or incorrectly set, and several building and equipment safety checks could not be evidenced.
“The lack of robust risk management processes meant people were not protected from harm or injury.” from the report
Staffing and training
seriousRecruitment checks were incomplete in all three files reviewed. Staff deployment left people waiting for help, and important training had not been completed by many staff.
“People were left for long periods of time with no engagement from staff, and there was a lack of staff presence around the communal areas.” from the report
Food and fluid records
seriousStaff did not always know people's nutritional needs, and food and fluid intake records were inaccurate. Inspectors also found limited snacks and a lack of suitable choice for some meals.
“Plates from people who had not eaten any food were cleared away, however records were completed to show these people had eaten.” from the report
Consent and restrictions
seriousThe home was not consistently following the Mental Capacity Act. Seven of 14 people subject to restrictions lacked the required assessments or best-interest decisions.
“We found the service was not working in line with the principles of the MCA.” from the report
Limited personal and social care
needs fixingCare plans did not consistently record people's preferences or current needs. People could spend long periods without meaningful interaction, and the garden was not freely accessible.
“We saw people sitting for long periods of time in their bedrooms and communal areas without any meaningful interaction.” from the report
- 01What has been done to make medicine storage, fridge temperature checks and topical cream records safe and reliable?
- 02How are you now making sure there are enough staff in communal areas and that people do not wait too long for help?
- 03Have all people subject to restrictions now had the required mental capacity assessments and best-interest decisions?
- 04How are food and fluid intake records checked for accuracy, especially for people at risk of poor nutrition?
- 05How have care plans been updated to record people's current needs, personal preferences, bathing choices and guidance for distressed behaviour?
This inspection began as a focused check of Safe, Caring and Well-led after the previous action plan, but it was widened to include Effective and Responsive after concerns about consent and person-centred care planning. This explanation was written from the published report of 14 February 2024 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, June 2023
Rated Inadequate and placed in special measures; inspectors found serious risks in medicines, safety, staffing, dignity and leadership.
This was an unannounced focused inspection. Inspectors visited on 4 and 6 April 2023, spoke with people, a relative and staff, and checked care, medicine and staff records. The inspection began on 4 April and finished on 2 May 2023.
The home was rated Inadequate overall. Safe, Caring and Well-led were also rated Inadequate. Inspectors found medicines were not managed safely, risks were not followed up, staffing was not deployed effectively, and people were not always treated with dignity or offered choices.
The home had been rated Requires Improvement at the previous inspection, published in December 2021. Problems with medicines had not been corrected. The overall rating fell to Inadequate, and the home was placed in special measures.
Safeguarding systems
The home had systems to report safeguarding concerns. Most staff had completed safeguarding training, and referrals had been made when incidents occurred.
“Where safeguarding incidents had occurred, referrals had been made to the local authority safeguarding team and notified to CQC.” from the report
Mental capacity processes
Inspectors found capacity assessments and best-interest decisions where needed. Deprivation of Liberty Safeguards applications and conditions were monitored.
“Where people lacked the capacity to make their own choices and decisions we found capacity assessments, and best interest decisions were completed.” from the report
Infection control
Inspectors were assured that the home had arrangements for preventing and managing infections, including the use of protective equipment and visits.
“We were assured that the provider was using PPE effectively and safely.” from the report
Manager responded to concerns
The manager accepted the issues raised during the inspection and took some immediate action, including in response to unsafe manual handling.
“The manager was open and honest throughout the inspection and took action where shortfalls and safety concerns were raised about poor manual handling techniques.” from the report
Medicines were not managed safely
seriousMedicines were sometimes unsecured, storage temperatures were not checked, records were incomplete and some doses were given too early. The report says this continued a breach from the previous inspection.
“Medicines were not always stored safely and securely.” from the report
Risks were not followed through
seriousCare plans and safety measures were not always followed. Inspectors saw unsafe moving and handling and found gaps in records about pressure care, food and continence care.
“The lack of robust risk management processes meant people were not protected from harm or injury.” from the report
Dignity and choice
seriousPeople were sometimes left without adequate privacy or clothing, and staff did not consistently respond to calls for help or offer choices about drinks and snacks.
“People were not always treated with respect, dignity and compassion.” from the report
Staffing and recruitment
seriousStaff were not always deployed where they were needed, and the mix of skills on one unit was not suitable. Several recruitment files had missing or incomplete documents.
“The provider had failed to deploy enough suitably competent and experienced staff to meet the needs of people in the service.” from the report
Weak leadership and oversight
seriousAudits had identified some shortfalls but there was no effective follow-up. The home also did not manage weight loss, accidents and incidents well enough to learn from problems.
“Systems to assess, monitor and improve the service were not sufficiently robust.” from the report
- 01What has changed to make sure medicines are stored securely, given at the correct time and fully recorded?
- 02How are risks such as falls, pressure damage, choking and unsafe moving and handling now assessed and checked?
- 03How many staff are deployed on each unit, and how do you make sure the staff mix is suitable for people's needs?
- 04How are people now offered choices and protected when they need help, privacy or reassurance?
- 05What action has been taken to improve audits, follow up incidents and monitor weight loss?
This was a focused inspection that covered Safe, Caring and Well-led; Effective and Responsive were not inspected, and the overall rating used the findings from this inspection alongside ratings from the previous inspection. This explanation was written from the published report of 17 June 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.
Every inspection of Acacia Bank Care Home
6 rated inspections over 8 years: the service has slipped, from Requires improvement to Inadequate.
- February 2024Inadequatecurrent ratingstayed InadequateSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- June 2023Inadequatedown from Requires improvementSafe: InadequateCaring: InadequateWell-led: Inadequate
- December 2021Requires improvementup from InadequateSafe: Requires improvementWell-led: Requires improvement
- April 2021Inadequatedown from GoodSafe: InadequateWell-led: Inadequate
- December 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2016Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2015
Report published without a new overall rating.
- October 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 25 January 2011.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
99 live-in carers within about an hour of Bradford
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,250 a week. 87 can care for a couple. 12 years' experience on average.
“Carla has been a god send with the implementation of bringing mum back home from respite care.”
“She understands the needs of an elderly person in the early stages of dementia and has treated my mother with great kindness and skill.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.