CQC report explained · a nursing home
What the CQC found at Acacia House - Tenterden
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found medicines were managed safely and infection control arrangements were in place. They identified missing daily fluid targets, falls training that had fallen behind and outstanding electrical remedial work.
- Effective?
- Good
- This area was not assessed in this targeted inspection.
- Caring?
- Good
- This area was not assessed in this targeted inspection, although relatives told inspectors they were very satisfied with the care.
- Responsive?
- Good
- This area was not assessed in this targeted inspection.
- Well-led?
- Good
- This area was not assessed in this targeted inspection. Inspectors noted that the two registered managers were working with quality assessors to identify and address improvements.
What inspectors found, November 2020
Inspected but not rated; the previous overall rating was Good, with safe medicines and infection controls but some improvements needed.
This was an unannounced targeted inspection on 3 November 2020. Inspectors checked specific concerns about medicines, risk management and infection control. They reviewed records, medicines systems and the building, and spoke with staff, relatives and a health professional.
Inspectors found that medicines were managed safely. They also found risk assessments, infection control measures and personal protective equipment in place. Relatives said they were very satisfied with the care and that their family members were well cared for and happy.
Some improvements were needed. Daily fluid targets were not written on monitoring sheets, falls training had fallen behind, and electrical remedial work was still outstanding. The service was inspected but not rated because this visit did not cover the whole service. Its previous overall rating was Good.
Safe medicines systems
Inspectors found safe systems for ordering, storing and giving medicines. Records, medicine counts, audits and staff competency checks were in place.
“Medicine audits were carried out weekly and monthly.” from the report
Infection control
Inspectors were assured that the home had measures for PPE, testing, social distancing, hygiene and managing possible outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Positive family feedback
Relatives told inspectors that people were well cared for and happy.
“They commented that relatives were well cared for and happy.” from the report
Risk planning
People's care and environmental risks had been assessed, with measures in place to reduce those risks.
“Risk assessments of people's needs and their home environment were in place with control measures to minimise risk and keep people safe.” from the report
Fluid monitoring
needs fixingDaily fluid targets were not written on monitoring sheets. This could make it harder for staff to see when someone was drinking less than recommended.
“Daily fluid targets were not added to monitoring sheets to alert and inform staff should fluid intake fall below the recommended daily amounts.” from the report
Falls training
needs fixingAction was taken when people fell, but staff training in this area had fallen behind after trained staff left.
“Appropriate action to report and act on falls was taken, but staff training had fallen behind in this area, following the departure of previously trained staff.” from the report
Electrical remedial work
needs fixingOutstanding work on the electrical installation was still in progress. Inspectors asked for an update to confirm that the work would meet current standards.
“However outstanding remedial works were ongoing for the electrical installation.” from the report
- 01Have the daily fluid targets now been added to people's monitoring sheets?
- 02What falls training has been completed by staff since the inspection?
- 03Has the outstanding electrical remedial work been completed, and what checks confirm it meets current standards?
- 04How are medicines audits and daily medicine checks being reviewed now?
- 05What areas will be covered at the next comprehensive inspection?
This was a targeted inspection of specific concerns about medicines, risk management and infection control; it did not assess the whole service, so the previous ratings were not changed. This explanation was written from the published report of 27 November 2020 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, September 2017
Rated Good; inspectors found kind, safe care and clear improvement since the previous inspection, but some records and recruitment checks needed attention.
Inspectors visited on 1 and 2 August 2017 without telling the home in advance. They spoke with people living there, relatives and staff. They observed care, meals, medicines and activities, checked parts of the building, and examined care records and staff files.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People were supported by enough staff, received medicines safely, and had access to health professionals. Inspectors also found caring relationships, personalised care and a range of activities.
The home had improved since the previous inspection in May 2016. Medicines were being managed safely, end of life wishes were recorded, people were more involved in care planning, and quality checks were more effective.
Inspectors still identified areas to improve. These included one delayed criminal record check, care plans not always reflecting professional advice or recent changes, unclear hydration targets, the use of pet names for people, and limited follow-up of some meeting suggestions.
Safe medicines
Medicines were stored securely and records showed that doses were given and signed for. Regular audits were used to check medicines were managed safely.
“The records were up to date and had no gaps, showing all medicines administered had been signed for.” from the report
Kind and respectful care
Inspectors saw positive relationships between staff and people. Staff respected privacy and dignity, listened to people and supported independence.
“There were positive and caring interactions between the staff and people and people were comfortable and at ease with the staff.” from the report
Personalised support
Care plans included people's histories, preferences, communication needs, risks and health needs. Staff showed they knew people well and adapted their approach.
“Within people's plans were life histories, guidance on communication and personal risk assessments.” from the report
Activities and social contact
People could choose from activities such as music, quizzes, bingo and entertainers. Staff also spent time with people who stayed in their rooms.
“People told us they were supported to take part in a variety of activities including music therapy, physiotherapy, quizzes, bingo, singers and entertainers.” from the report
Improved management checks
Audits covering medicines, accidents, safety, infection control, fire safety and equipment were being completed. Inspectors found these checks identified shortfalls and led to action.
“The audits identified any shortfalls and action was taken to address them.” from the report
Recruitment checks
needs fixingOne staff member's DBS check was not completed before they started work. Some references for staff starting their first job at the home had been provided by friends and were of limited value.
“Additionally although overseas criminal records checks were completed, the DBS check for one member of staff was not completed before they started work at the service” from the report
Care plans not always updated
needs fixingAdvice from a speech and language therapy team was being followed in practice but was not included in the relevant care plans. Some care plan reviews did not reflect important recent changes.
“However, we found although staff were working to current guidance from visiting health care professionals, instructions they had provided were not always incorporated into care planning.” from the report
Hydration targets
needs fixingStaff recorded food and fluid intake, but hydration charts did not state the target amount needed. This made it harder to see how close someone was to their desired intake.
“We did however discuss with the registered manager that hydration charts may be more meaningful for staff if they stated the target amount of hydration people needed.” from the report
Use of pet names
minorSome staff called people names such as 'Darling' and 'love'. Inspectors said this did not fully recognise people as individuals and could cause confusion, especially for people living with dementia.
“Although people did not object it did not project the ethos of a service that recognised individuals.” from the report
Following up suggestions
minorPeople and relatives could give feedback, but meeting records did not always show what had happened to earlier suggestions. Inspectors said meetings should include updates from previous meetings.
“It was, however, not clear from one meeting to the next how items of discussion had been actioned or acted upon.” from the report
- 01Has every staff member now had the required criminal record and reference checks completed before working unsupervised?
- 02How do you make sure advice from speech and language therapists and other health professionals is added promptly to care plans?
- 03Do each person's hydration records now include a clear daily target, and who checks these records?
- 04How do you make sure staff use each person's name and communicate in a way that suits people living with dementia?
- 05Can you show how suggestions from residents' and relatives' meetings are recorded, acted on and reported back?
This was an unannounced inspection of the overall service, including all five CQC questions, care and medicine observations, the environment, records, staffing and feedback from people, relatives and staff. This explanation was written from the published report of 16 September 2017 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 House - Tenterden
2 rated inspections over a year: the service has improved, from Requires improvement to Good.
- November 2020Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- September 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 2014
Report published without a new overall rating.
- May 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- April 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 3 November 2010.
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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Most charge £980 to £1,260 a week. 33 can care for a couple. 12 years' experience on average.
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