The inspection took place on 7 February 2017 and was unannounced. Acorn House provides accommodation and support for up to ten adults with learning disabilities. Accommodation is provided over three floors in a large semi-detached Edwardian building located in a residential area. At the time of the inspection there were ten people living at the home. They had a range of learning disabilities and some people were also living with long term conditions such as dementia and diabetes.

We last inspected Acorn House on 15 December 2015 when we identified a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because potential risks to people’s health, safety and well-being were not being consistently managed. After the inspection the provider wrote to us to say what they would do to meet the legal requirements. At this inspection we checked to see if the required improvements had been made and whether the provider was meeting the requirements of the Health and Social Care Act 2008. We found that improvements had been made, however further areas of concern were identified.

The service had a registered manager. 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. At the time of the inspection the registered manager was on maternity leave and the deputy manager was in charge.

Risks to people were not always identified, assessed and managed. This meant that suitable arrangements were not always in place to minimise risks to people and staff. Staffing levels were not always adequate to ensure that people’s needs would be met safely. These issues were identified as areas in need of improvement. Since the inspection CQC have received confirmation that all these areas have been addressed.

There were safe recruitment arrangements in place to ensure that staff were suitable to work with people. Staff understood their responsibilities with regard to safeguarding people. Medicines were managed safely and some people were supported to manage their own medicines. People told us that they felt safe living at Acorn House. One person said, “I feel safe here, it’s a very nice place to live.”

Staff received the support they needed to carry out their roles effectively. Training was planned and included subjects that were relevant to the needs of people they were caring for. Staff understood their responsibilities with regard to the Mental Capacity Act. People told us that they had confidence in the staff, one person said, “They know how to look after me.”

People were supported to have enough to eat and drink and they were able to choose the food that they wanted. Where risks and nutritional needs were identified, people were supported and monitored appropriately and advice was sought from dietary and nutritional specialist. People told us they enjoyed the food and drink, one person told us, “The food is very, very nice, you can choose from the menu and I can get drinks when I want.”

Staff supported people to access the healthcare services that they needed. People’s records included clear health care plans and referrals were made quickly when people’s health needs changed.

People said that staff were kind and caring and we saw that they had developed positive relationships with the people they were caring for. Staff knew people well and spoke of them warmly with affection. People were supported to express their views and to be involved in planning their care. One person told us, “I can choose what I wear and how to spend my time, I like to go out sometimes, it’s up to me.” People had been supported to make their wishes known regarding arrangements for end of life care.

People’s care plans were personalised and included de

Our inspection team was made up of one inspector. We answered our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

CQC monitors the operation of the Deprivation of Liberty safeguards which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place. Relevant staff have been trained to understand when an application should be made and how to submit one.

Systems were in place to make sure that all staff learnt from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. Feedback was sought from people and their relatives which helped the service develop and learn.

Is the service effective?

People told us they were happy with the care that had been delivered and their needs had been met. It was clear from our observations and from speaking with staff that they had a good understanding of the people’s care and support needs and that they knew them well.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. One person told us “Living here is good. Here I have everything I want. For example, I’m going on holiday with my keyworker in July.”

Is the service responsive?

People’s needs were continually assessed. Records confirmed people’s preferences, interests, aspirations and diverse needs had been recorded and support had been provided in accordance with people’s wishes. People had access to activities that were important to them and were supported to maintain relationships with their friends and relatives.

Is the service well-led?

Staff had a good understanding of the ethos of the home and quality assurance processes were in place.

During our inspection we spoke with six people who used the service. We also spoke with the manager and three support workers. We looked at information, including residents' care files and other records, to help us understand how Acorn House operates.

We found that consent was obtained for major decisions and for day-to-day activities.

People’s care needs were assessed and support was planned and delivered to meet those needs with regard to residents' personal preferences. One person told us, “It’s nice here. I have a nice bedroom.” Another person said, “I can talk with staff and with my keyworker.”

We found the provider has not taken steps to provide care and support in an environment that is adequately maintained.

Staff have appropriate skills and experience. However, not all required checks were always completed before people started work or were evidenced in the appropriate staff files.

We also saw that the service have record systems in place to monitor the quality of the service provided.

During our inspection we found that care workers had formed close professional relationships with people living in the home. The service was found to be well managed. The premises were clean and generally well maintained and the atmosphere was relaxed and homely.

As far as practicable and in accordance with their individual care plans, people were enabled and supported to make choices about their daily lives. They had input into how the home was run and were able to influence decision making processes. Despite people’s limited verbal communication care workers had developed awareness and a sound understanding of each individual's complex care and support needs. This was evident from direct observation of individuals being supported in a professional, sensitive and respectful manner.

Communication and consultation with people's family members was effective and ongoing.

Positive comments received from people living in the home and their relatives indicated a high level of satisfaction with the home and the services provided:

“I like living here and why wouldn’t I? The staff are wonderful, I have everything I need – and it’s my home”.

“The level of care provided is very good the manager and staff are excellent. It gives us peace of mind knowing that she is being so well looked after and her needs are being met. She certainly wouldn’t have stayed there for over 20 years if she wasn’t happy there or we had any concerns about the home”.

During our visit to Acorn House, the service was found to be well managed. The premises were clean and well maintained and the atmosphere was relaxed and homely.

As far as practicable and in accordance with their individual care plans, people are enabled and supported to make choices about their daily lives. They have input into how the home is run and are able to influence decision making processes.

Overall people clearly enjoy living in the home. Although levels of communication are variable, people appeared happy and settled and many spoke positively about the staff and the care that they receive. This was evident from direct observation of individuals being supported in a professional, sensitive and respectful manner.

We inspected Acorn House on 15 December 2015. It provides accommodation and support for up to ten people. Accommodation is provided over three floors in a large semi-detached Edwardian building. The building is located within a residential area.

People living at Acorn House range in age from 54 to 81 years. The home provides care and support to people living with a range of learning disabilities and a variety of longer term healthcare needs such as dementia and diabetes. Several people had lived at the home for a number of years and were in a settled friendship group. There were the maximum permitted ten people living at the home.

We last inspected Acorn House on 15 April 2014 where we found it to be compliant with all areas inspected.

A registered manager was in post. 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 and associated Regulations about how the service is run. The deputy manager had applied to be a second registered manager and the application was in process at the time of our inspection.

Potential risks to people’s health, safety and well-being were not consistently well managed. A relative of the provider was lodging at the home. Suitable checks into the background of the individual to protect people were not carried out. The arrangement had implications for the provider’s home insurance. We have identified this as an area of practice that requires improvement.

The maintenance of an area of the home had not been maintained to a high enough standard. People were exposed to an environment where cleanliness was not maintained across all areas, increasing risk from poor hygiene maintenance. We have identified this as an area of practice that requires improvement.

People appeared happy and relaxed with staff. It was clear staff and the management had spent considerable time with people, getting to know them, gaining an understanding of their personal history and building rapport with them. A relative said, “Staff are friendly and patient. It’s like a family home. I have nothing but praise.”

There were sufficient staff to support people. When staff were recruited, their employment history was checked, references obtained and an induction completed. Checks were also undertaken to ensure new staff were safe to work within the care sector. Staff were knowledgeable and trained in safeguarding and knew what action they should take if they suspected abuse was taking place. A range of specialist training was provided to ensure staff were confident to meet people’s needs.

People were provided with a choice of healthy food and drink ensuring their nutritional needs were met.

People’s needs had been assessed and detailed care plans developed. Care plans contained risk assessments for a wide range of daily living needs. For example, a person had a risk assessment around using public transport and this had changed as their needs evolved. People consistently received the care they required, and staff members were clear about people’s individual needs. Care and support was provided with kindness and compassion. Staff members were responsive to people’s changing needs.

People’s health and wellbeing was continually monitored and the provider regularly liaised with healthcare professionals for advice and guidance. A healthcare professional told us, “My experience has been that the staff and management are good at seeking appropriate input with regards to individuals health needs, be that from specialist learning disability services or mainstream services.”

Medicines were managed safely in accordance with current regulations and guidance. There were systems in place to ensure that medicines had been stored, administered, audited and reviewed appropriately.

The CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We found that the deputy manager understood when an application should be made and how to submit one. Where people lacked the mental capacity to make specific decisions the home was guided by the principles of the Mental Capacity Act 2005 (MCA) to ensure any decisions were made in the person’s best interests.

People were provided with opportunities to take part in activities ‘in-house’ and to regularly access the local and wider community. People were supported to take an active role in decision making regarding their own routines and the routines of their home. One relative said, “[My relative] has been in one previous home but here they really look after her. [The manager] brings her down her to visit me and I can see that they get on famously. I am very impressed.”

Staff had a clear understanding of the vision and philosophy of the home and they spoke enthusiastically about working at the home and positively about the management of the home. The registered manager or their deputy undertook regular quality assurance reviews to monitor standards in the home and drive improvement.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.