CQC report explained · a residential care home
What the CQC found at Acacia Lodge Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People's risks were assessed and reviewed, medicines and infection control were managed safely, and safety checks and certificates were up to date. Inspectors noted that recruitment risk assessments needed to be more accurate, and people said staffing levels could sometimes be improved.
- Effective?
- Good
- This key question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- Staff were observed treating people with kindness, empathy and respect. People were involved in care planning and supported to remain as independent as possible, although three people were waiting for lunch when a health professional attended.
- Responsive?
- Good
- This key question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Good
- The home had regular audits, checks, meetings and handovers. People, relatives and staff spoke positively about the management and said they had confidence in the leadership.
What inspectors found, January 2023
Rated Good, down from Outstanding; inspectors found safe, kind care and good leadership, but staffing pressure and some recruitment risk assessments needed attention.
This was an unannounced inspection on 19 and 25 October 2022. Inspectors spoke with people living at the home, relatives, staff and a visiting health professional. They reviewed care files, staff files, medicines records, audits and safety records.
The home was rated Good overall. Safe, Caring and Well-led were rated Good. Inspectors found that people were protected from harm, medicines were managed safely, staff were kind and people were involved in their care. They also found good management checks and confidence in the leadership.
The inspection was prompted by a notification after a person died. CQC did not examine the circumstances of that incident, which remained subject to further investigation. Inspectors found no evidence during this inspection that people were at risk from the related concern about equipment. The overall rating fell from Outstanding to Good, while Safe remained Good and Caring and Well-led fell from Outstanding to Good.
Safe medicines management
Medicines were managed through an electronic system. Staff were trained, checked for competence and followed guidance tailored to people's needs and preferences.
“Staff managed people's medicines safely.” from the report
Kind and respectful care
People and relatives described staff as kind and caring. Inspectors saw sensitive interactions and support that encouraged people's independence.
“People told us staff were very kind and respectful.” from the report
Strong leadership
People, relatives and staff had confidence in the management. Audits and meetings were used to monitor care and act on issues.
“There was a positive culture at the service.” from the report
Learning from incidents
Accidents and incidents were recorded, reviewed and discussed with staff. The home also shared learning from incidents at other homes in the group.
“Learning from incidents and accidents was discussed, shared with the staff team and acted upon.” from the report
Recruitment risk records
needs fixingInspectors were assured that people remained safe, but risk assessments for some prospective staff did not accurately explain the level of risk or how it had been reduced.
“Whilst we were assured people remained safe, these needed to more accurately reflect the level of risk and how this had been mitigated.” from the report
Staffing pressure
minorInspectors found enough staff to meet people's needs in the main, but staff were under pressure on one unit at lunchtime. People also said they could sometimes do with more help.
“Having more staff would be good; sometimes I could do with more help;” from the report
Lunch-time dignity
needs fixingThree people were waiting to be served lunch when a health professional attended. Inspectors said this was not dignified practice, and the manager took steps to prevent it happening again.
“On the first day of inspection a visiting health professional attended to 3 people who were waiting to be served their lunch.” from the report
- 01What has changed in staffing arrangements since inspectors saw staff under pressure at lunchtime?
- 02How do you now record and review risks linked to prospective employees?
- 03What steps were taken to make sure people are not left waiting for meals in an undignified way?
- 04What are the current ratings and most recent findings for Effective and Responsive, which were not inspected in this visit?
- 05What can you tell us about any further CQC investigation linked to the incident mentioned in the report?
This was a focused inspection of Safe, Caring and Well-led; Effective and Responsive were not inspected and their previous ratings were used in the overall rating. This explanation was written from the published report of 12 January 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, September 2019
Rated Outstanding; inspectors found exceptionally caring, well-led support, with one issue about delays in local authority DoLS applications.
This was a planned inspection over two days on 10 and 11 July 2019. It was unannounced on the first day. Inspectors spoke with people living in the home, relatives, staff and health professionals. They observed lunch and interactions, and checked care plans, medicines, staff records and quality checks.
The home was rated Outstanding overall. Caring and Well-led were Outstanding. Safe, Effective and Responsive were Good. Inspectors found person-centred care, strong leadership, kind staff, good activities and thorough care planning.
The home had improved from Good at the previous inspection. Inspectors found no medicines errors and no breaches of regulations. They noted that the local authority was not up to date with some applications for Deprivation of Liberty Safeguards, although the home had put interim care plans and records in place.
Personalised care
Care plans included detailed information about people's needs, preferences, histories and wishes. Staff used this information to provide individual support.
“Plans of care were extremely person centred and the details gave staff the information they needed to deliver individualised care.” from the report
Kind and respectful staff
Inspectors saw strong relationships between people and staff. People's dignity, privacy, faith, sexuality and independence were respected.
“We observed people who used the service and staff had a good rapport and staff knew people very well.” from the report
People had a voice
People and relatives helped shape activities, meals, the environment and some recruitment decisions. They were encouraged to take part in running the home.
“The registered manager had created an extremely positive culture where people, staff and relatives had ownership, made decisions and took pride in being involved in some aspects of running the home.” from the report
Strong leadership
Managers used regular audits, meetings and feedback to monitor quality and make improvements. Staff were supported to develop specialist knowledge.
“The registered manager conducted many comprehensive audits around the quality of service provision.” from the report
Meaningful activities
People could choose from individual and group activities, including music, singing, gardening, shopping and community trips. Families were also welcomed.
“The service provided many meaningful opportunities for people to mix socially with each other and their families.” from the report
Delay with DoLS applications
minorThe report says the local authority was not up to date with applications completed by the home. The home used interim care plans and kept records while waiting for authorisation.
“However, the local authority was not up to date with the applications the service had completed.” from the report
- 01How do you currently track DoLS applications while waiting for the local authority to respond?
- 02How will you make sure my relative's care plan is updated quickly if their needs change?
- 03How many staff are normally available on each floor and how do you respond when staffing changes?
- 04Which activities would match my relative's interests, communication needs and cultural or religious preferences?
- 05How can relatives give feedback, attend meetings or raise a concern, and how quickly will it be addressed?
This was a comprehensive inspection covering all five CQC questions, with the previous Good rating reviewed across the service. This explanation was written from the published report of 21 September 2019 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 Lodge Care Home
3 rated inspections over 6 years: the service has held its Good rating throughout.
- January 2023Goodcurrent ratingdown from OutstandingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2019Outstandingup from GoodSafe: GoodCaring: OutstandingWell-led: Outstanding
- December 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- November 2011
Registered with the Care Quality Commission on 29 November 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.
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