Archived: Acacia Lodge - London

Updated 10 September 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

We undertook an unannounced comprehensive inspection of the service on 11 July 2016.

The inspection team consisted of two inspectors, an inspection manager and an expert-by- experience. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Before the inspection we reviewed information we held about the service in our records. This included information sent to us by the provider relating to the management of risk on a monthly basis. We also reviewed safeguarding alerts and notifications of important events at the service.

As part of the inspection we looked at four staff recruitment records, three supervision records for staff and the training matrix for the team. We spoke with the registered manager, provider and five members of the staff team including the administrator and the chef.

We spoke with three people who used the service and we spent time watching the interactions between staff and people using the service. We also used a Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. We looked at care records for seven people living at the service.

We reviewed documents relating to medicines, audits carried out by the service and we also inspected the building. Following the inspection we have spoken to two health and social care professionals and four family members.

Updated 10 September 2016

We carried out an unannounced comprehensive inspection on 11 July 2016. At our previous inspection on 17 March 2016 we carried out a focused inspection to see whether improvements had been made following an enforcement notice we had served against the provider in relation to safe care and treatment in December 2015.

At the inspection in March 2016 we judged that the provider had made improvements and had met the requirements of this enforcement notice. Whilst improvements had been made we were unable to change the rating for safe.

.Acacia Lodge is a privately run residential home for up to 32 older people, some of whom are living with dementia. The home also provides a respite service. There were 23 people living at the home at the time of our inspection.

There is a registered manager at the service. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At this inspection we found that significant improvements had been made to risk assessments overall. There was still one risk assessment missing as it did not address a risk situation identified in the care plan, and one risk assessment without guidance for staff to mitigate the risk. These have since been completed by the service. The registered managed had developed quality assurance systems. We saw these were in place and were broad ranging and audits were carried out on a regular basis. However, they had not picked up the missing risk assessment.

We have made a recommendation that the service reviews its auditing procedure to ensure it is fully effective.

Staff had been carefully recruited and there were enough staff to meet people's needs. Staff felt supported and there was evidence of supervision taking place across the last 12 months. Training had taken place in relevant areas so staff had the skills and knowledge to offer a good service.

Staff knew how to recognise and report any concerns or allegations of abuse and described what action they would take to protect people against harm. Staff and people using the service told us they felt confident any incidents or allegations would be fully investigated, and this was confirmed by relatives.

People were supported to have a healthy diet and spoke highly of the food provided by the service. The service had recently been awarded five stars (highest rating) for food hygiene. The service’s premises were clean and we could see there were systems in place to maintain good infection control.

There was a record of essential services such as gas and electricity and being checked, and equipment safely maintained. There was also clear documentation relating to complaints and incidents.