CQC report explained · a residential care home
What the CQC found at Acacia Mews Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, safe recruitment, individual risk assessments and appropriate medicines systems. The home was clean and had infection control arrangements.
- Effective?
- Good
- Staff were trained and supported. People received suitable food and drinks, healthcare support and care based on assessed needs and choices.
- Caring?
- Good
- Staff treated people with kindness, dignity and respect. They knew people well and supported independence and personal choices.
- Responsive?
- Good
- Care plans were personalised and reflected people's needs and preferences. People had activities, outings and support to maintain relationships and interests.
- Well-led?
- Good
- Inspectors found an open culture, approachable management and effective checks on the quality and safety of care. Staff worked well as a team.
What inspectors found, February 2020
Rated Good; inspectors found safe, kind and personalised care, with the registered manager absent during the visit.
This was an unannounced planned inspection on 14 January 2020. Inspectors spoke with nine people, three relatives and six staff. They observed care and checked care, medicines, recruitment, training and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People and relatives said they were happy with the care. Inspectors found enough staff, good training, safe medicines practices and care that reflected people's needs and choices.
People were treated with kindness and respect. They had access to activities, outings, healthcare and a varied diet. The home had systems for handling concerns and learning from incidents.
The overall Good rating was unchanged from the previous inspection, published on 14 July 2017. The registered manager was absent during this visit, but the deputy manager was running the home and feedback about the arrangements was positive.
Enough staff
People, relatives and staff said there were enough staff. Inspectors saw staff respond promptly and spend time with people.
“People and their relatives told us they felt there were enough staff to meet their needs.” from the report
Kind relationships
Staff knew people as individuals and treated them with respect. Inspectors saw reassuring, attentive interactions.
“As a result, people told us they felt valued, respected and cared about.” from the report
Personalised support
Care plans were person-centred and staff understood what mattered to each person, including communication needs and daily preferences.
“They were person centred, easy to follow and captured what was important to people.” from the report
Activities and community links
People could take part in activities, outings and community connections. The home provided a regular activities planner.
“People were taken for walks to the local Dementia Café, or to the local Supermarkets, a minibus was available for longer outings” from the report
Registered manager absent
minorThe registered manager was not present during the inspection. The deputy manager was managing the home in their absence, and inspectors reported positive feedback about this arrangement.
“However, the registered manager was absent at the time of inspection and the home was being managed by the deputy manager.” from the report
Care records being transferred
minorSome records were still in transition as the home moved from paper to electronic care plans. Inspectors said this did not affect how people were supported.
“Some records were in a transitional period while the service moved from paper to electronic care plans.” from the report
- 01Who is managing the home now, and what arrangements are in place when the registered manager is absent?
- 02Has the move from paper to electronic care plans been completed, and how are records checked for accuracy?
- 03How will you assess and review my relative's individual risks and changing care needs?
- 04What activities and outings would be suitable for my relative, and how often could they take part?
- 05How can my relative or our family raise a concern, and how are grumbles and complaints followed up?
This was an unannounced planned inspection covering all five CQC questions, with the overall rating and each area rated Good. This explanation was written from the published report of 4 February 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, July 2017
Acacia Mews is rated Good; inspectors found safe, kind and personalised care, with some training and privacy issues to improve.
This was an unannounced comprehensive inspection. Inspectors visited on 27 and 28 July 2017, spoke with people, relatives and staff, observed care, and reviewed care plans, staff files and management records.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, suitable risk assessments, safe medicines arrangements and support for people's nutrition, hydration, choices and independence.
People and relatives described staff as kind and respectful. Care plans were personalised and activities were available. The home had systems for handling complaints and checking quality, although some staff training was behind schedule and one concern about giving an injection in a communal area was raised.
The home was also rated Good at the previous inspection in July 2015. This inspection found that it remained Good.
Enough staff
Inspectors found enough suitably experienced staff, and call bells were answered promptly. Staffing levels had been increased when people's needs changed.
“There were enough suitably experienced, skilled and qualified staff available at all times to meet people's needs safely and effectively.” from the report
Kind and respectful care
Staff were observed treating people warmly and respectfully. They supported privacy, dignity and independence.
“We saw kind and caring interaction between staff and the people who used the service.” from the report
Personalised care
Care plans reflected people's individual needs and preferences. People and relatives were involved in creating and reviewing them.
“Care plans were person centred and were reviewed regularly there was guidance available to support staff to meet people's needs.” from the report
Good oversight
Managers held daily meetings, carried out audits and used action plans when they found problems.
“Where issues were identified, action plans were developed to improve the service.” from the report
Training was behind schedule
needs fixingThe registered manager said staff training was behind schedule. The home was developing two new trainers to improve this area.
“However the registered manager confirmed that training was behind schedule and that they were in the process of developing two new trainers to help ensure this area improved.” from the report
Privacy during an injection
needs fixingA person told inspectors that an outside nurse had given another resident a diabetes injection at the dining table. Inspectors raised this with the manager, who said the practice would stop.
“We reported this to the registered manager and we were assured that this practice will be stopped.” from the report
More opportunities to go out
minorSome people said they would like to get out more. Inspectors made the manager aware of this.
“Some people we spoke with told us they would like to get out a bit more and we made the registered manager aware of this.” from the report
- 01What has been done to bring staff training fully up to date since the inspection?
- 02Where are injections and other treatments given, and how is people's privacy protected?
- 03What extra opportunities are now available for people who want to go out?
- 04How are staffing levels reviewed when people's needs increase?
- 05How are care plans reviewed with residents and their relatives?
This was an unannounced comprehensive inspection covering all five areas: Safe, Effective, Caring, Responsive and Well-led. This explanation was written from the published report of 14 July 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 Mews Care Home
3 rated inspections over 4 years: the service has held its Good rating throughout.
- February 2020Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2014
Report published without a new overall rating.
- April 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- January 2012
Registered with the Care Quality Commission on 3 January 2012.
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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