The inspection took place on the 13 December 2017 and was unannounced. At the last inspection in 2015 the service was rated as ‘good’ overall, but ‘requires improvement’ in the well-led domain, due to a lack of stable leadership. At this inspection there was clear and stable leadership in place. There were no breaches of Regulations identified at this inspection.

Acorn Hollow is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service is registered to provide nursing care and support for up to 48 older people. At the time of the inspection there were 43 people living at the service. The service is spread over two floors. The ground floor accommodates people with more complex nursing needs, whilst the first floor accommodates people with less complex needs.

There was a registered manager working at the service who had been registered with the CQC since October 2011. A registered manager is a person who has registered with the Care Quality Commission 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.

Staff had completed training in areas needed for them to carry out their roles effectively. This included training in areas such as moving and handling, safeguarding and life support. In one example the registered manager and another member of staff had provided cardiopulmonary resuscitation (CPR) to a visitor who had become unwell. This had resulted in this person’s life being saved. This demonstrated that staff had the skills necessary to deal with emergency situations.

People were protected from the risk of abuse. Staff had completed training in safeguarding vulnerable adults and were aware of the processes for reporting incidents. There was a whistleblowing policy in place which was displayed on the staff noticeboard. Staff were aware of this.

Recruitment processes were safe and there were sufficient numbers of staff in post to keep people safe. New staff had been required to provide two references, one of which was from their most recent employer. They had also been subject to a check by the DBS to ensure they did not have a criminal history. We reviewed staffing rotas which showed consistent numbers of staff were in place. This helped ensure people’s needs were being met in a safe manner.

People were supported to take their medication as prescribed. Medication Administration Records (MARs) were being signed by staff as required and medication was being stored securely, in line with legal requirements. People confirmed that they received their medication as prescribed.

People are supported to have maximum choice and control of their lives and staff support them in the least restrictive way possible; the policies and systems in the service support this practice. Information regarding people’s mental capacity was included in people’s care records and Deprivation of Liberty Safeguards had been applied for by the registered manager as required.

Risk assessments were in place to keep people safe. These were reviewed to ensure they stayed accurate and up-to-date and provided staff with the information they needed. This helped ensure that risks to people were safely managed.

Accidents and incidents were monitored and appropriate action taken in response to these to prevent them from occurring again in the future. For example where people were at risk of falls protective measures had been implemented, such as using movement sensors or bed rails to protect people.

Care records were in place which clearly outlined people’s needs and provided details to staff around what support they needed to provide. These were reviewed and updated on

This inspection took place on 15 January 2015 and was unannounced. We arrived at the home at 10am and left at 7.30pm. At our last inspection on 9 July 2013 the service met all of the regulations we inspected.

Acorn Hollow General Nursing Home is registered to provide personal and nursing care for up to 48 older people. On the day of the inspection 35 people were living in the home.

The home has single room accommodation over two floors. Each floor has two lounges, dining areas and bathing and toilet facilities. There is access into the garden, which has seating and tables.

The home had a registered manager who had been in post for three months. A registered manager is a person who has registered with the Care Quality Commission 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.

The registered manager had resigned from post and was working her notice, there was no deputy manager and only one full time permanently employed registered nurse, leading to a heavy reliance on bank and agency nurses. This had resulted in a reduction in formal supervision of care staff, which meant there was a risk that care standards might not be maintained.

However, people told us they felt safe living at the home, staff were kind and compassionate and the care they received was good. A relative told us they had no concerns about the way their family members were treated. Comments included: “The care is very good and the staff are very kind”; “They’re all very nice”; “They know me well and I’m quite happy here”; “The staff treat mum well and I’m happy with the care overall”.

People’s needs were assessed before they moved into the home and care plans were developed to identify what care and support people required.

Staff reviewed people’s needs regularly and people were referred to appropriate health and social care professionals to ensure they received treatment and support as required.

People received visitors throughout the day and we saw they were welcomed and included.

The staff ensured people’s privacy and dignity were respected. We saw that bedroom doors were always kept closed when people were being supported with personal care.

The people we spoke with said they enjoyed the food provided. One person said “It’s very nice, but there isn’t much choice and sometimes I feel I haven’t had enough and I’m hungry”. Another said “The food’s ok and I get an ample amount”. Other people we spoke with said there were always drinks and snacks available; “You only have to ask”.

We saw that people could choose how to spend their day and they took part in activities in the home and the community. The home employed an activity organiser who engaged people in activities in small groups during the day.

Staff had received training in how to recognise and report abuse. All were clear about how to report any concerns. Staff spoken with were confident that any allegations made would be fully investigated to ensure people were protected.

People knew who to speak to if they wanted to raise a concern and there were processes in place for responding to complaints.

Some people who used the service did not have the ability to make decisions about some parts of their care and support. Staff had an understanding of the systems in place to protect people who could not make decisions and followed the legal requirements outlined in the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS).

There were processes to monitor the quality of the service and we saw from recent audits that the service was meeting their internal quality standards apart from those relating to staff training and supervision.

We spoke to five people who used the service. They said they were getting the care and support they needed. They described the staff as helpful and supportive. Some comments made were: - “The staff are very good. They are there when you need them and always ready to help.” “I would prefer to be at home but I’m very well looked after here.” “The staff are good. I’m happy here.”

We spoke to two relatives who were also happy with the care and support provided. Some comments made were: - “The staff are attentive and very nice.” “The home was recommended to me and I would recommend to others. The staff do a good job. My relative is well cared for.”

During our visit we observed that staff were respectful, attentive and had a caring attitude towards the people who used the service. When people asked for support they received a good response.

We found that people had been assessed before they began to use the service and they had care plans that identified their needs and any risks to their well-being.

There were good systems in place to promote infection control.

People were cared for and supported by, suitably qualified, skilled and experienced staff.

There was a clear complaint system and other ways in which people could make their views known about the service.

An expert by experience spoke with eleven people who used the service and three relatives.

The people who used the service said that they liked the flexibility of living at Acorn Hollow. They liked being able to get up and retire to bed when they liked.

The people who used the service said that they were always treated with respect. They were generally positive about the staff. Some comments made were:-

“I won’t fault the staff.”

“The staff are lovely.”

“The staff are polite and nice.”

The expert by experience reported that the home had a well kept garden. The bedrooms and corridors were clean and well-kept. The bedrooms were made personal to the occupants. The layout and access to the stairs promoted people's safety. One of the lounges on the first floor was a little cluttered.

The expert by experience reported that the people spoken with all thought that the staffing levels were insufficient. They said the staff appeared “pushed” and said that the staff answered call bells and promised to return to assist but they were either delayed or did not return.

The expert by experience reported that the eleven people who used the service and two of the relatives appeared to have little knowledge of a care plan. One relative spoken with had been involved in drawing up a care plan and they considered that this had resulted in more effective care being provided.

The majority of the eleven people who used the service told the expert by experience that the meals were "tolerable". They said that soup and sandwiches were nearly always served at tea time. Two people who had a special diet said there was little variety to the meals provided. Some people said that the portions were too large.

We asked the commissioners of the service and the local safeguarding co-ordinator for their views. No issues of concern were raised by the safeguarding co-ordinator. The commissioning team reported there had been an issue over the management of medication within the last twelve months that had been appropriately managed.

We requested information from Cheshire West and Chester Local Involvement Network (*LINks). At the time of writing this report no information was received from this agency.

* LINKs are networks of individuals and organisations that have an interest in improving health and social care services. They are independent of the council, NHS and other service providers. LINks aim to involve local people in the planning and delivery of services.