This inspection took place on 28 February 2017 and was unannounced.

Acorn House Residential Home Limited provides accommodation and personal care for up to 20 older people. Some people were living with dementia; some people had mobility difficulties and sensory impairments. Accommodation is arranged over two floors. The home is situated on a busy road close to Chatham town centre. There were 20 people living at the home on the day of our inspection.

There was a registered manager employed at the service. 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 was on maternity leave but visited the service during the inspection to take part.

At the last Care Quality Commission (CQC) inspection on 01 April 2015, the service was rated as good in all of the domains and had an overall good rating. Since the last rated inspection, the provider had changed their registration so that they could provide care and support for people living with dementia as well as older people. This was the first inspection since the changes had been made. The owners of the home had also changed.

At this inspection, we found the service remained Good but required improvement in the effective domain.

People and their relatives provided positive feedback about the service they received, staff and the management team.

The decoration of the home did not follow good practice guidelines for supporting people who live with dementia. We made a recommendation about this.

There were procedures in place and guidance was clear in relation to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS), which included steps that staff should take to comply with legal requirements. Staff had limited understanding of the MCA and DoLS, however staff gave people choices throughout the day and helped them to make decisions. We made a recommendation about this.

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards. The providers and registered manager understood their responsibilities under the DoLS. The registered manager had systems in place to monitor DoLS and had taken action to meet DoLS conditions.

People continued to be safe at Acorn House Residential Home. People were protected against the risk of abuse. People told us they felt safe in the service. Staff recognised the signs of abuse or neglect and what to look out for. The provider’s own safeguarding policy required updating to provide staff with accurate information about which local authority to report abuse to. We made a recommendation about this.

Medicines were managed safely and people received them as prescribed. Staff knew how to protect people from the risk of abuse or harm. They followed appropriate guidance to minimise identified risks to people's health, safety and welfare. There were enough staff to keep people safe. The providers had appropriate arrangements in place to check the suitability and fitness of new staff.

Each person had an up to date, personalised care plan, which set out how their care and support needs should be met by staff. These were reviewed regularly. Care plans did always not detail people’s abilities so it was not clear what people could do for themselves. People’s interests and hobbies had not always been incorporated into the care plans to enable staff to provide person centred activities to keep people stimulated and active.

Staff received regular training and supervision to help them to meet people's needs effectively.

People were supported to eat and drink enough to meet their needs. They also received the support they needed to stay healthy and to access healthcare services.

Staff en

The inspection was carried out on 1 April 2015 by two inspectors and an expert by experience. It was an unannounced inspection. The service provides personal care and accommodation for a maximum of 20 older people. There were 12 people living there at the time of our inspection.

No one using the service at the time of our inspection was living with dementia. People had varied communication needs and abilities. People were able to express themselves verbally.

There was a manager in post whose registration with the Care Quality Commission was in process. 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 were trained in how to protect people from abuse and harm. They knew how to recognise signs of abuse and how to raise an alert if they had any concerns. Risk assessments were centred on the needs of the individual. Each risk assessment included clear measures to reduce identified risks and guidance for staff to follow or make sure people were protected from harm.

Accidents and incidents were recorded and monitored to identify how the risks of re-occurrence could be reduced. There were sufficient staff on duty to meet people’s needs. Staffing levels were calculated and adjusted according to people’s changing needs. There were safe recruitment procedures in place which included the checking of references.

Medicines were stored, administered, recorded and disposed of safely and correctly. Staff were trained in the safe administration of medicines and kept relevant records that were accurate.

People lived in a clean and well maintained environment that was suited to meeting their needs. All fire protection equipment was serviced and maintained. The building was warm and welcoming. People’s own rooms were personalised to reflect their individual tastes and personalities.

Staff knew each person well and understood how to meet their support needs. Each person’s needs and personal preferences had been assessed before they moved into the service and were continually reviewed.

Staff’s training was renewed annually, was up to date and staff had the opportunity to receive further training specific to the needs of the people they supported. All members of care staff received regular one to one supervision sessions and were scheduled for an annual appraisal to ensure they were supporting people based on their needs and to the expected standards.

The Care Quality Commission (CQC) is required by law to monitor the operation of Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Whilst no one living at the home was currently subject to a DoLS, we found that the manager understood when an application should be made and how to submit one.

Staff sought and obtained people’s consent before they helped them. One person told us, “The workers don’t do anything unless I say they can”.

The service provided meals that were in sufficient quantity, well balanced and met people’s needs and choices. One person said, “The food is very good; we have two good cooks here”. Another person told us, “The puddings are really lovely”. Staff knew about and provided for people’s dietary preferences and restrictions.

Staff communicated effectively with people, responded to their needs promptly, and treated them with kindness and respect. People were satisfied about how their care and treatment was delivered. One person told us, “Everyone is kind and helpful”. Another said, “They are kind and very caring.”

People were involved in their day to day care. People’s care plans were reviewed with their participation and relatives were invited to attend the reviews and contribute.

Clear information about the service, the facilities, and how to complain was provided to people and visitors. Menus, activities programme and results of satisfaction surveys were displayed for people in a suitable format.

People were able to spend private time in quiet areas when they chose to. People’s privacy was respected and people were assisted with their personal care needs in a way that respected their dignity.

People were promptly referred to health care professionals when needed. Personal records included people’s individual plans of care, life history, likes and dislikes and preferred activities. The staff promoted people’s independence and encouraged people to do as much as possible for themselves.

People’s individual assessments and care plans were reviewed monthly with their participation and updated when their needs changed. A person told us, “They go through my file with me and my daughter every month to make sure nothing has changed and check it is still OK with us”.

People chose their preferred option from a range of activities and were involved in the planning of these activities. A relative told us, “I often say to Nan, can you fit me in? It always looks as if they are enjoying themselves”.

The service took account of people’s complaints, comments and suggestions. People’s views were sought and acted on. People’s relatives were asked about their views at each review of people’s care plan and when they visited the home. The manager sent bi-annual satisfaction questionnaires to people’s relatives or representatives, analysed the results and acted upon them. Staff told us they felt valued under the manager’s leadership.

The manager notified the Care Quality Commission of any significant events that affected people or the service. The manager kept up to date with any changes in legislation that may affect the service and carried out comprehensive audits to identify how the service could improve. They acted on the results of these audits and made necessary changes to improve the quality of the service and care.

The inspection was carried out over a period of just over eight hours by three inspectors. There were ten people who lived at the home on the day of inspection. People had a range of needs including difficulties with mobility and dementia. Some people had communication difficulties. This meant they were not always able to tell us about their experiences.

The report is based on our observations during the inspection, talking with six people who lived in the home, four staff who worked in the home, and reviewing records, policies and procedures. We also talked with the manager and provider.

During this inspection we set out to answer 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. If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

The home was well maintained and clean, improvements had been made to the internal decoration and some carpets had been replaced.

There were suitable levels of staffing to meet people’s needs.

Medicines were safely stored, administered and recorded.

Is the service effective?

There was a range of activities available to people. The home had booked an external activities company to come to the home to do motivational activities.

People were listened to. People told us that they had requested changes to the meals they were offered. They told us that these changes had been made. We saw that the requests had been discussed with the kitchen staff.

Sensory training had been booked to provide staff with further information and guidance.

People who required specialist equipment had been assessed by an occupational therapist to ensure they had the right equipment to meet their needs. The home had followed guidance provided by specialists.

Is the service caring?

People were supported by kind and attentive staff. We observed staff speaking with people in a respectful manner and respecting people’s privacy.

People told us that they were very happy living in the home. People were involved in making decisions, For example, people chose their meals and what activities they would like to do.

Is the service responsive?

Assessments and care plans had been updated to reflect people’s needs and were person centred. The home had responded to people’s physical and sensory needs and had made referrals for specialists to provide advice and guidance.

Complaints procedures were clearly displayed, the home had received one complaint since we last inspected, this had been dealt with swiftly and had been resolved.

Is the service well led?

An experienced manager was in place. People told us the manager was easy to talk to. Staff told us they were well supported by the manager. The manager had developed good systems and had made significant changes to the home.

The provider had worked with the manager to ensure that the home was regularly checked. Any concerns or issues found in the checks had been dealt with. Repairs and maintenance had been carried out in a timely manner.

We spoke to seven people who lived in the home. They were all positive about the support that they received from the care staff at the home. One person said, “Staff treat me like a human being” and another person said that, “Staff treat me well and do the best that they can in a difficult situation”. We saw that when staff spoke to people they were polite and respectful.

Care plans varied in the level of detail that they contained, but generally contained most of the information that staff required to support people with their personal, and health care needs.

People were not protected against the risks of abuse or unsafe care and treatment. This was because immediate action had not been taken to safeguard people when staff voiced concerns about the care and treatment of people who lived in the home.

Potential fire risks in the home had not been assessed so that action could be taken to minimise them. In addition, people could not be assured that they would be safely evacuated in the event of a fire.

The culture in the home did not ensure that people were confident about raising complaints or assure them that if they do so, that their concerns would be acted on.

Appropriate systems were not in place for gathering, recording and evaluating information about the quality and safety of the care, treatment and support that the service provided.

Staff communicated with people who lived in the home in a respectful manner. One person told us, “Staff respect us all times and are very kind”. Another person said, “Staff are lovely. We have a laugh together”.

Care plans did not all contain information about people's assessed needs or give clear instructions to staff so that they knew how to look after people safely. Comprehensive risk assessments had not always been carried out detailing the steps that had been taken to minimise the risks to people who lived in the home.

There were safe procedures in place for the administration of medication. We saw that medication was given to the right person at the right time.

The home did not regularly monitor the service so that it could identify if any improvements needed to be made for the benefit of the people who lived in the home.

Most of the people that we spoke to were satisfied with the support that they received. One person told us,” If you have got a complaint, it is dealt with quickly”. However, two of the ten people that we spoke with did not feel that the home listened to and responded to their concerns. “I’ve told the staff about it but nothing ever gets sorted in this place”, one person told us. Therefore, not everyone who lived in the home felt that they were listened to and that their concerns were acted upon.

People told us that that they were satisfied with the care that they received at the home. One person told us, "I like it here......I do bingo in the afternoon. There is a variety of things going on".

Feedback from quality assurance questionnaires completed by relatives were mainly positive about the standard of care. Comments included: "My mother has always been treated with the greatest respect, I cannot fault the staff, manager and owner; they have done a fantastic job". "A lovely well run place. I'm very happy with everything…a bit more entertainment could maybe arranged". "Mum has really been enjoying the little taste of seasonal treats recently. She has told me of strawberries and cream. A lovely gesture".

We used a number of different methods to help us understand the experiences of people using the service, because some people were not able to tell us their experiences. We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand people's experiences.

People told us that they were satisfied with the care and support that they received from the staff team. People told us that care staff 'popped in' to see them to make sure that they were alright. A visitor told us that their relative was, "left in good hands".

People told us that care staff acted on any health concerns that they had.

People told us that the food was good, but that sometimes there was a delay in it being served.

People said that they were comfortable in their bedrooms. They told us that they had all the things that they needed. They said that they had been able to bring in their own belongings when they first moved to the home.

Some people told us that they liked to spend a lot of time in their bedrooms, and other

people told us that they liked to go and talk to people in the lounge.

People told us that the care staff were always kind and courteous.

Relatives told us that they were kept informed about people's health and welfare.

People were mostly positive about the care and support that they received from the care staff team. A number of people told us that one care staff in particular always made them feel better by their cheerful and jovial nature. "She has a laugh and a joke with me…. She is good to me".

Some people and some relatives told us that there were not many activities on offer at the home. One person said, "there is a lack of stimulation". Other people told us that there are regular church services at the home. They also said that the PAT (Pets as therapy) dogs visited.

Some people told us that they liked to play bingo and had done so yesterday. However, they told us that the game had been, "cut short", as the care staff who had organised it, had been called away.

People told us that the care staff were always busy.

People said that they were not asked daily about their meal choices. However, they said that if they did not like something on the menu, they could ask for something else.

People told us, "The cook is excellent".

People told us that they thought that it was expected when they moved to the home, that they would have breakfast in their bedroom each morning.

Some people told us that they liked to spend a lot of time in their bedrooms, and other people told us that they liked to go and talk to people in the lounge.

People who lived in the home and relatives told us that they would speak to someone if they were not happy with any aspects of the care at Acorn House. They said that they felt confident that these people would sort out any concern that they had, to their satisfaction.

Our inspections of 27 May 2014 and 17 June 2014 were conducted by two inspectors at each visit. We visited the home a second time as we had received concerning information through our whistle blowing procedures. When we inspected on the 27 May 2014 a new manager was in post. When we inspected on the 17 June 2014 the new manager had left without giving notice. The owner told us that they were advertising for a new manager. A deputy manager had been put in place to manage the home.

There were 16 people living in the home at the time of our first visit and 13 people were living at the home at the time of our second visit. Some people had communication difficulties. This meant they were not always able to tell us about their experiences. This report is based on our observations during the inspections, talking with people who used the service, one relative, staff and reviewing records.

During these inspections we set out to answer 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. If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

We found that people who used the service were protected from the risk of abuse because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. The provider and staff were aware of their responsibilities for keeping people safe and clear guidance was available for staff.

We saw that care plans reflected people’s choices. We saw that one person had returned from hospital with significantly increased care needs. Their care plan had not been updated to reflect the changes.

We found that the building had not been suitably maintained and posed a potential risk to people. We also noted damaged furniture which could injure people who lived in the home. Some windows in the home required maintenance work as frame holding the secondary glazing in place had broken.

We saw that there was not enough staff on duty in all areas of the home to keep people safe from harm.

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

We have asked the owner to make improvements and meet the requirements of the law in relation to keeping people safe from harm.

Is the service effective?

People told us they were happy with the care that they received at the home. It was clear from our observations and from speaking with staff that they had a good understanding of people’s care and support needs. We saw that people’s needs had been assessed and they had been involved in planning for their care where possible. Best interests meetings were held when people lacked the capacity to make decisions about their care.

The home had not followed the guidance given by a dietician and had not contacted the dietician to advise that they were concerned about a person’s reducing food and fluid intake.

One person told us that they were not able to join in with activities as the home did not cater for their needs as they had a visual impairment. We saw that the home did have some activities for people who had a visual impairment. The home had not included information about people's sensory impairments within assessments undertaken.

We have asked the owner to make improvements and meet the requirements of the law in relation to meeting the needs of people who live in the home.

Is the service caring?

People were supported by kind and attentive staff. We observed positive interactions between staff and people living at the home. We saw that people enjoyed spending time in the company of the staff who supported them. Two of the people who lived at the home told us that the staff were “Lovely”. One person told us “Acorn is a very nice place” and another person said “I like it very much”. They described the staff as “All very nice girls”. We spoke with five people who lived at the home. They were positive about their experiences.

At our inspection on the 17 June 2014 we had serious concerns about the care and welfare of some of people who lived in the home. We found one person who was left in bed with no access to staff for up to an hour at a time. The person was too frail to sit themselves up and use the call bell.

We saw that care plans reflected people’s choices. For example, one person’s care plan showed that they preferred to get up at 07:15 in the morning. The daily records showed us that this person had been supported to get up at this time each day.

Is the service responsive?

We saw that the home had taken steps to ensure that people’s views were sought and actions were taken as a result of what people told the provider. People were asked about what activities they would like to have at the home and we saw that changes had been made in response to suggestions from people who lived at the home.

Some processes were in place to monitor the quality of the service and audits had been introduced to ensure that regular checks were made on different aspects of the service.

We found some areas of the home had not been cleaned satisfactorily. We also found that infection control guidelines had not been adhered to which put people at risk of infection.

We have asked the owner to make improvements and meet the requirements of the law in relation to reducing the risk of exposure from a healthcare associated infection and identifying, assessing and managing risks relating to health, welfare and safety of people who live in the home.

Is the service well-led?

At our inspection of 2 December 2013 we found that people were not protected against the risks of abuse or unsafe care and treatment. This was because the provider had not taken steps to address safeguarding concerns at the home in a timely manner. Potential fire risks in the home had not been assessed so that action could be taken to minimise them. The culture at the home did not ensure that people were confident about raising concerns due to the manner of a previous senior staff member. Appropriate systems were not in place for gathering, recording and evaluating information about the quality and safety of the care, treatment and support that the service provided.

At our inspection of 27 May 2014 we found that the provider had taken steps to address concerns in relation to their understanding of safeguarding procedures and they had attended appropriate training. A fire risk assessment had been carried out and the provider had ensured that all recommendations had been acted on. Systems had been introduced to monitor the quality of the service and we saw that residents and relatives had been provided with a forum to make their views known. However, some systems that had been introduced were not effective as they had not identified issues that we found during our inspection. For example, infection control audits had not checked dining room chairs.

Staff we spoke with told us that the provider and senior staff at the home were approachable and we saw evidence that they were regularly meeting with staff. Staff told us they were clear about their roles and responsibilities. We saw that systems were in place to manage complaints appropriately.

We have asked the owner to make improvements and meet the requirements of the law in relation to assessing the quality of services provided by the home.