This inspection took place on 15 and 19 December 2016 and the first day was unannounced. At our previous inspection in August 2015, we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to deprivation of liberties, managing storing and administering medicines, assessing need, and providing training. At this inspection we found the home had made improvements in all these areas.

Acorn Lodge is a privately owned care home. It offers nursing and residential care and support for up to 85 older people, some of whom have a diagnosis of dementia. There are four units, but at the time of our inspection one unit was closed as the home was undergoing some refurbishment, and this unit was in the process of renovation. When we inspected Acorn Lodge there were 61 people living there. The home is located in located in Failsworth, close to Oldham and the city of Manchester and is a large purpose built care home with a secure garden. All rooms are single and some have en-suite facilities.

There was no registered manager in post at the time of inspection. The former registered manager had left in November 2015. A new manager had been in post for three months and had submitted an application to register with CQC. 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.

When we spoke to people who used the service they told us they felt Acorn Lodge was a safe place and that they felt secure. We saw that there were systems were in place to protect the safety and welfare of the people who used the service. When we spoke to staff at Acorn Lodge, they demonstrated a good understanding of safeguarding adult procedures, and we saw that recruitment procedures were sufficiently robust to help ensure that people were protected from the risk of unsuitable staff being recruited.

We found there were sufficient numbers of staff to meet people’s needs in a timely way. The provider had recently recruited some staff and worked hard to reduce sickness levels. Rotas showed that shifts were covered and there was less reliance on the use of agency staff. One care worker told us, “Sickness has gone down and morale has gone up. Staff are smiling and are happier”. All staff had access to a computer based eLearning package to improve their skills and knowledge.

At our last inspection we found that the service was not managing medicines in a safe way. We found at this inspection that the service had reviewed medicine protocols, and there were systems to ensure that medicines were managed, stored and administered safely.

Where risk was identified plans were put into place to minimise harm. Care plans were detailed and subject to regular review. Attention was paid to people’s dietary and nutritional needs, and the service supported people to make lifestyle choices around their food. People who used the service told us they had sufficient to eat and drink.

We saw that arrangements were in place to assess whether people were able to consent to care and treatment, and people were offered choices about how their care was delivered.

Where health needs were identified, the staff at Acorn Lodge liaised with appropriate health professionals, such as doctors, district nurses and dieticians to ensure that health needs were not neglected.

We saw examples of kind and caring support, and one person who used the service told us, “The staff really make an effort to get to know us, and they are so kind. Nothing is too much trouble.”

Systems were in place to ensure that people at the end of life received appropriate care in accordance with their wishes, and were supported with the relevant healthcare as needed.

Care plans documented people’s inter

Acorn Lodge is a purpose built care home offering accommodation and support for up to 85 people, 83 in single rooms and one double room. At the time of our visit there were 50 people living at the home.

The inspection was undertaken by two inspectors. This summary addresses five key questions: is the service safe; is the service effective; is the service caring; is the service responsive and is the service well led?

This summary is based on a visit to the home where we spoke to the manager and observed staff interactions with people using the service. We looked at records and talked with seven visiting relatives, eight people using the service and seven members of staff. We also spoke with a visiting health care professional.

The full report contains the evidence to support this summary.

Is the service safe?

Overall the people we spoke with at the inspection visit were positive about the care provided by the home. Visitors who we asked told us they thought their relatives were safe. One visitor said “I have never seen any incidents of inappropriate behaviour [from staff]” and “I have never seen anyone not treated as an equal”. Another visitor told us “I’ve got some sleep since [relative] has been here”.

People told us they were confident they could complain if they needed to.

Staff who we spoke with told us they believed people using the service were protected from abuse or exploitation.

There was documentary evidence that most staff had received training in the safeguarding of vulnerable adults. This was confirmed by staff who we asked. Staff also told us they understood the need to be vigilant and, to whistle blow if necessary.

We undertook a tour of the building. This included communal areas and a selection of people’s bedrooms. No obvious hazards to people’s health and safety were seen. Staff were provided with disposable gloves and aprons to help minimise the risk of cross infection. Infection control and health and safety audits were undertaken.

Is the service effective?

Each individual’s care needs were assessed and reviewed. A care plan was developed on the basis of the assessment.

People who used the service told us they were involved in the development of their care plan. One person said “The staff listen to me about how I want to be cared for”.

Staff who we spoke with understood the importance of delivering care in a ‘person centred’ way. One member of staff told us “People are individuals, what works for one person may not work for another. It’s important to get to know what works for the person in getting a positive response”.

There was evidence that people were referred to community based health care professionals if their support was necessary.

Is the service caring?

Observations of interactions between staff and people who used the service indicated a calm and respectful atmosphere. Staff were seen to focus on the individual and take time to explain what they were doing.

Comments from people who used the service and visitors included: “I have always found the care good here”; “I’m very happy with the care my relative has. The staff are marvellous”; and “[staff are] always very helpful. Always willing to help if we ask”.

Is the service responsive?

We did not look specifically at the service’s complaints procedure. However, people using the service and visitors who we asked during our visit said they believed they would be listened to if they had a complaint. One visitor told us that the manager was “helpful” and “looks into issues”. Another person told us “I know staff listen to me”.

We saw that there was an effective quality monitoring (QM) and quality assurance (QA) system. This meant that the service was able to identify and respond to any shortfalls in the service, as well as recognising the strengths of the service people received. The QM and QA system included reporting on actions which would further improve the service.

Satisfaction surveys had been distributed, but not many had been returned. The manager held monthly meetings where relatives could attend to express their views.

Is the service well led?

For several years this service has fluctuated between compliance with the required standards and non compliance with them. This is indicative of the management structure’s failure to provide good and consistent leadership over time. Since the last inspection the service provider had engaged a management company to assist in the management of the home. A new manager had also been recruited with the intention of continuing after the management company withdrew.

At the time of this visit the new manager was still consolidating their position. It was too soon after their appointment to assess fully if they would be able to maintain consistently good leadership at this service. However, everyone who we spoke with who expressed a view, spoke positively about the impact of the new manager. Staff talked about the manager as being pro-active and approachable. Staff told us they were more involved in the care planning and that things were “really improving”. Comments from visitors included “The new manager is helpful” and “[the new manager] seems respected by staff. She is very fair and very interactive”.

At the time of this inspection visit, 67 people were living at the home. We saw that many people staying at the home had complex health care needs such as dementia and some people had nursing care needs.

We spoke with four people staying at the home and with visiting relatives for two people. Two people said “The staff work very hard”. One person said “Everything is lovely” when asked about the care. Visitors for two people with complex care needs said they were satisfied with the care their relative received. One visitor said, “The girls [staff] are excellent”.

People told us that they were involved in their care and visitors told us that they were kept up to date about their relative’s progress. We heard from people and visitors that they felt confident to raise any concerns or complaints with staff and the manager.

We looked at the care records for three people. We saw one care file needed updating and another care record contained very generalised information. We observed one person had to wait about 20 minutes for assistance and another person was moved in a wheelchair without footplates potentially putting the person at risk from injury.

We found that the management of medication was safe. One person told us it was their preference that staff administered their medication.

We saw that records of new staff recruitment were appropriate.

We visited Acorn Lodge Nursing Home because we had received some concerning information about the service provided at the home. The information we received identified concerns with care practices, the management of the home and cleanliness in the home. Whilst on this inspection visit we also checked to see if the provider had addressed the improvement action we made following our previous inspection in December 2012.

During our visit, we spent most of our time on the nursing dementia care unit on the first floor. Due to the complex care needs of people with dementia, they were unable to tell us of their experiences of living in the care home.

However, we did speak to two visitors who were relatives of people living in the home. One visitor said their relative had stayed in another care home but was much more settled and had put on weight in this care home. They told us they now had “peace of mind.” Another visitor told us they were very “happy” with the care their relative received. They said the staff were “pleasant and polite” and they were kept informed about their relative’s health and care issues. They told us there were rare occasions when they had visited and their relative had not been shaved. They said staff explained the reasons for this and reassured them that their relative care needs would be addressed.

In addition, to assist our inspection we carried out a Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to helps us assess and understand whether people who use services and who are unable to talk to us are receiving care that is appropriate

Our observations showed that almost all the care staff were attentive and caring. They were patient, offered people choice and gave explanations when providing assistance. We saw that people were clean, tidy and dressed in accordance with their preferences.

We spoke with health and social care commissioners (contractors with the home) for the service and they confirmed that they were working with the provider and manager to improve and develop the service provided.

We visited Acorn Lodge on the 16 December 2011. People who live at Acorn Lodge told us that the “the staff are excellent”, “I can’t praise them enough”. A relative said the she had “no complaints whatsoever”

We were told by three people who live at Acorn Lodge and one visitor that the food was excellent. One person told us that she had never eaten poppadoms before. She said that she really enjoys them with her curry.

People told us that they were treated with respect. We heard that “staff are really caring and pleasant towards everyone”. We were told that any issues or problems were sorted by the management team.

Staff and several people who live at Acorn Lodge, told us that that there had been lots of improvements since the new owner and management team took over in August 2010. One person told us “It’s smashing here, now.” and another person said “The staff are different; they are nicer now since the old staff have gone. You feel more cared for and staff listen to you”.

We were also told that the care home had been decorated and that new beds and chairs had been purchased.

This was an unannounced inspection which took place on 22 and 25 August 2015. We had previously inspected this service in 16 September 2014 when we found it was meeting all of the regulations we reviewed.

Acorn Lodge Nursing Home is registered to provide accommodation for up to 85 older people who require support with nursing or personal care needs. At the time of our inspection there were 63 people living at Acorn Lodge.

Acorn Lodge Nursing Home is a purpose built home located in Failsworth, close to Oldham and the City of Manchester. There are 83 single rooms and one shared room. Forty-eight rooms have en-suite facilities. A passenger lift is provided.Personal care is provided to older people on the ground floor and general nursing care and nursing care for people with dementia and / or mental ill health is provided on the first floor.

During the inspection we saw that the home was being cleaned however, we were aware of offensive odours in the home.

There was a registered manager in place at Acorn Lodge. 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.

We found five breaches 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

At the time of the Inspection 21 people were subjected to DoLs. Prior to the inspection we checked our records to see if we had received any DoLs notification by the provider. Our records indicated that the provider had not notified us appropriately of all people subjected to DoLs.

This was a breach of regulation

11 (1)(2)(3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

We found that people were not protected against the risks associated with the promoting and administering of their medicines. The provider did not have any protocols in place for medicines prescribed to be taken as needed. We also find that one person’s prescribed medication; ‘Thick and Easy’ was being given to other residents. The provider did not have safe systems in place to make sure medicines were prompted or administered as prescribed.

This was in breach Regulation 12 (1)(2)(g) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

On reviewing care records we identified that the registered manager had not completed an initial needs assessment for a person admitted for End of Life care, to identify the needs of the individual and to ensure that the individual’s care needs could be met.

This was a breach of regulation 12 (1)(2)(a)of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

We looked at the records in relation to one person who required regular repositioning in order to maintain their skin integrity. The lack of timely information being recorded on the repositioning chart meant there was no evidence to show that the person had received the care they required to meet their individual needs in accordance to the planned needs.

This was a breach of regulation

12 (1)(2)(a)(b) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

All the staff we spoke with told us they had received an induction, ongoing training and supervision to help ensure they were able to deliver effective care. We saw that staff were supported to continue to develop knowledge and skills for the benefit of people who used the service.

There was a detailed Induction for all agency nursing staff, however there was no induction for agency care workers and gaps in training for staff who had returned to work after a long break.

All staff should receive appropriate induction and training to ensure they can safely fulfil their roles and responsibilities.

This was a breach of regulation 18(1)(2)(a) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

People who used the service told us they felt safe in Acorn Lodge and that there were always sufficient numbers of staff to meet their needs. Relatives we spoke with told us they did not have any concerns about the safety of their family member in Acorn Lodge.

Recruitment processes were sufficiently robust to protect people who used the service from the risk of unsuitable staff being employed to work in the home. All the staff we spoke with had received training in the safeguarding of vulnerable adults and knew the correct action to take if they had any concerns about a person who used the service.

Care records included an assessment of the risks people might experience including those related to mobility, falls and nutrition. Risk management plans were in place to provide information to staff about the action they should take to help reduce such risks from occurring.

People who used the service told us staff were kind and caring in their approach. We saw staff took time to speak to people and help them make decisions, such as what they wanted to eat or where they wanted to sit. We observed staff meeting the needs and preferences of the people they were supporting on the day of the Inspection.

Staff were aware of the principles of the Mental Capacity Act (MCA) 2005: this legislation provides legal safeguards for people who may be unable to make their own decisions. The registered manager had assessed the capacity of people who used the service to consent to the care and treatment they required. Where necessary, applications had been made to the local authority to ensure any restrictions in place were legally authorised under the Deprivation of Liberty Safeguards (DoLS). We were not notified of all DoLs applications made to the Local Authority.

People we spoke with made positive comments about the quality of food provided in Acorn Lodge and systems were in place to ensure peoples nutritional needs were met. However we observed during the inspection the poor presentation of food, no choice of cold drinks offered throughout the day and no fresh fruit readily available to.

Records we looked at showed that a regular programme of activities and entertainment was provided. Plans were in place to introduce materials to support reminiscence work in the service and the new activity coordinator has arranged for local churches of all denominations to visit the home regularly.

People who used the service and their relatives had the opportunity to comment on the service provided in Acorn Lodge through regular meetings and an annual survey as well as through more informal feedback to staff. We were told by people that staff and managers would always listen to any concerns or comments made and would take action to ensure concerns were immediately addressed.

Staff told us they enjoyed working in the service and considered the managers were approachable and supportive. Regular staff meetings took place which allowed staff the opportunity to comment on the service provided and identify where they felt any improvements which could be made.

We saw lack of regular structured opportunities for people to provide feedback on the service they received and to comment on service developments. This meant there was a risk people’s views would not be listened to or acted upon.

The overall rating for this service is ‘Requires Improvement’

Services require improvement will be kept under review and, will be inspected again within six months.