This inspection took place on 26 and 27 November 2018 and was unannounced.

Acorn Nursing Home 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 care home can accommodate up to 34 older people and older people living with dementia in one adapted building. Accommodation is provided over two floors.

At our last inspection in July 2017, we rated the service as requires improvement overall. At this inspection, we found the service had improved to an overall rating of good.

There was a registered manager in post. 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 recruited safely and there were enough staff to take care of people and to keep the home clean. Staff were receiving appropriate training and they told us the training was good and relevant to their role. Staff told us they were well supported by the registered manager. Formal supervision and appraisals were in place where staff could discuss their ongoing development needs.

We saw people were treated with respect, kindness and compassion. People who used the service and their relatives told us staff were helpful, attentive and caring.

Care plans detailed what care and support people wanted and needed and were mostly kept up to date. Risk assessments were in place which showed actions that had been taken to mitigate any identified risks. People felt safe at the home and appropriate referrals had been made to the safeguarding team when necessary.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

Medicines were stored and managed safely and people’s healthcare needs were being met.

Staff knew about people’s dietary needs and preferences. People told us there was a good choice of meals and said the food was good. There were plenty of drinks and snacks available for people in between meals.

Some activities were on offer to keep people occupied either within small groups or on an individual basis. Visitors were made to feel welcome and offered refreshments by staff.

The home was spacious, clean and tidy. An ongoing programme of refurbishment was underway with some windows requiring replacement and plans to remodel the garden area.

The complaints procedure was displayed, although no complaints had been received since the last inspection. Procedures were in place to ensure any complaints received would be dealt with appropriately.

Everyone spoke highly of the registered manager and said they were approachable and supportive. The provider had effective systems in place to monitor the quality of care provided and where issues were identified, actions were taken to make improvements.

We found all the fundamental standards were being met. Further information is in the detailed findings below.

The inspection took place on 18 and 26 July 2017. It was unannounced on the first day.

Acorn Nursing Home is a thirty-four bedded care home, which provides residential and nursing care. Bedroom accommodation consists of both double and single rooms situated on the ground and first floor of the building. There are communal rooms on the ground floor. There is ample car parking space at the front of the property and at the back there is an enclosed garden.

The last inspection report was published in January 2017. At that time the service was rated as requires improvement overall and was rated inadequate in the well led domain. The service was in breach of three regulations, two of these being continued breaches from the previous inspection report published in April 2016. The breaches were in relation to Regulation 10 (Dignity and respect) Regulation 17 (Good governance) and Regulation 18 (Staffing). The service remained in Special Measures because it was rated as inadequate in one of the key questions at two consecutive inspections. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

There was a registered manager in place. 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 noted the provider is registered for the regulated activity of personal care which is associated with the provision of services to people living in their own homes. We found no evidence they were delivering this kind of service and following the last inspection we asked them to submit an application to remove this regulated activity from their registration.

People told us they felt the home was a safe place. Staff knew how to report any concerns about people’s safety and welfare. The service supported some people to manage their personal money and in most cases records were kept of all transactions. However, in one case where money was being provided by a person’s relative appropriate records were not maintained. We recommended records be maintained of all transactions involving money spent on behalf of people living at the home.

There were enough staff to keep people safe although people who lived at the home and relatives told us staff always seemed very busy. The required checks were done before new staff started work and this helped to protect people from the risk of receiving care and treatment from staff unsuitable to work with vulnerable adults. Staff received the training and support they needed to carry out their duties safely and properly.

Risks to people’s safety and welfare were identified and managed. The home was clean and was being refurbished, people told us it had improved over recent months in both cleanliness and décor. The gardens were in need to attention to make them safe and suitable for people to use.

People’s medicines were managed safely.

People were supported to eat and drink and action was taken in response to unplanned weight loss. People’s special dietary needs and preferences were catered for. People’s meal time experiences had been improved due to changes in the way meal times were managed.

People were supported to have access to the full range of NHS services to maintain their health and wellbeing.

The service was working in accordance with the requirements of The Mental Capacity Act 2005 which helped to make sure people's rights were protected.

We saw staff were kind and patient an

The inspection took place on 18 October 2016 and was unannounced. There were 25 people living at the home when we visited.

The last inspection was carried out in January and February 2016 and the report was published in April 2016. At that time we found the service was in breach of seven regulations. We found people were not adequately protected from harm and the recruitment procedures were not robust. People’s rights were not protected because the service was not working in accordance with the requirements of The Mental Capacity Act 2005 and people were not treated with dignity and respect. People’s medicines were not managed safety and records were not properly maintained. The service did not have a proper way of dealing with complaints and the governance arrangements were not effective. The service was rated as ‘Inadequate’, we served warning notices and requirement notices and the service was placed in ‘Special Measures’. We carried out this inspection to check if the required improvements had been made.

Acorn Nursing Home is a thirty-four bedded care home, which provides residential and nursing care. Bedroom accommodation consists of both double and single rooms situated on the ground and first floor of the building. There are communal rooms on the ground floor. There is ample car parking space at the front of the property and at the back there is an enclosed garden which is accessible to people living in the home.

We noted the provider is registered for the regulated activity of personal care which is associated with the provision of services to people living in their own homes. We found no evidence they were delivering this kind of service and therefore have asked them to submit an application to remove this regulated activity from their registration.

There was 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 the service is run.

Staff working in the home knew how to recognise and report any concerns about people’s safety and welfare. We found improvements had been made and more safeguarding concerns were being identified and reported. This assured us there was less risk that any abuse which did take place would be undetected.

There were enough staff on duty. However, the home did not employ enough nurses to make sure there was one nurse on duty at all times without using temporary or agency staff.

No new staff had been employed since the last inspection and we were not able to check if the correct recruitment procedures were being followed.

We found improvements had been made to the way people’s medicines were managed.

We found the home was generally clean, safe and well maintained. The provider was continuing with the refurbishment programme. However, on the day we inspected the conservatory was cold and the radiators were not working all day.

Individual risks to people’s safety and welfare which were as a result of their care needs were not always managed safely. This had been a concern at the last inspection and therefore we concluded the provider remained in breach of regulation.

Although staff told us they felt supported the training records showed a significant number of staff had not received any training on safe working practices such as fire safety and moving and handling. In addition, the majority of staff had not received training on privacy and dignity which had been identified as an area of concern at the last inspection. We found this was a breach of regulation.

People were offered a variety of food and drinks and their dietary needs, likes and dislikes were catered for. People’s nutritional status was assessed and appropriate action was taken if people were having difficulty eating or had unpl

The inspection took place on 26 January and 04 February 2016 and was unannounced. There were 29 people living at the home at the time of the inspection.

Acorn Nursing Home is a thirty-four bedded care home, which provides both residential and nursing care. The home was formerly a vicarage and it is less than one mile from Bradford City centre and close to St Luke's Hospital. The home is well served by public transport and there is adequate parking to the front of the property. Bedroom accommodation consists of both double and single rooms situated on the ground and first floor of the building.

The last inspection was carried out on 7 May 2014. At that time there were two breaches of regulations which related to the safety of the premises and the systems in place to assess and monitor the quality of the services provided. The provider sent us an action plan and assurances that the concerns about the premises had been addressed. During this inspection we checked to see if the required improvements had been made. We found the specific issues relating to the premises had been addressed. However, we found the systems for monitoring and assessing the quality and safety of the services provided had not improved. There has been a change to the regulations since the last inspection and therefore we have mapped the continued failure of the quality assurance processes to the new regulations.

There was 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.

People who used the service and relatives did not raise any concerns about safety however we found a number of issues which led us to conclude the service was not safe. We found risks to people’s safety and welfare were not always identified and managed properly. For example, we found risks to people’s safety due to unlocked storage areas and uneven floor surfaces had not been acted upon until we brought them to the attention of the registered manager. We identified problems with the way the disposal of clinical waste was being managed.

We found people’s medicines were not managed safely.

There were enough staff deployed to meet people’s needs. However, we found the required checks were not always done before new staff started work and this meant people were at risk of being cared for by staff who were unsuitable to work with vulnerable people. We found the records of staff training and support were not properly maintained and therefore could not be assured staff had received the training and support they needed to carry out their duties effectively.

The service was not working in accordance with the requirements of the Mental Capacity Act 2005 and therefore people’s rights were not always protected.

We found people were not always treated with respect, dignity and compassion. Some of the language used by staff when speaking about people who lived at the home was not appropriate or respectful.

People were offered a varied range of food and drink and special dietary needs were catered for. However, we found the meal service was rushed and chaotic and people missed the opportunity to enjoy the social aspect of meal times. When people’s dietary intake was being monitored we found the food and fluid charts were poorly completed.

We found people and their relatives were not consistently involved in making decisions about their care and treatment. Many of the care plans we looked at did not provide information about people’s individual needs and preferences.

Information about the complaints procedure was not easily accessible to people and the providers procedures for dealing with complaints were out of date.

People were given the opportunity to take part in a ran

The inspection visit was carried out by two inspectors. During the inspection, we spoke with the home manager, care staff, people who used the service and relatives of people who used the service. We looked around the premises, observed staff interactions with people who lived at the home, and looked at records.

We considered all the evidence we had gathered under the outcomes we inspected.

We used the information to answer the five key questions we always ask;

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well led?

This is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service, their relatives and the staff told us.

Safe -

We found there were generally sufficient staff on duty to meet people’s needs throughout the day and night. When necessary the service used agency staff to cover absences. One person who used the service told us there were occasions when the home was short of staff on night duty and this meant they had to wait when they needed support from staff.

The Registered Manager told us they were in the process of implementing a twilight shift, (6pm to 10pm), because they had identified some of the people who used the service needed additional support in the evenings. One person who used the service said they did not have to wait long for staff when they used the call bell in their room. People’s relatives told us they visited regularly and said there were always staff around to attend to people’s needs.

In the care records we looked at we saw people had risk assessments which covered areas of potential risk such as pressure ulcers, falls and nutrition. When people were identified as being at risk, their plans showed the actions required to manage these risks.

There were procedures in place to guide staff on the actions to take in response to medical emergencies.

The manager understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). They were aware of the recent Supreme Court judgment on the Deprivation of Liberty Safeguards and said they had arranged a meeting with the local DoLS team to discuss the implications for the service.

When we looked around the home we identified some risks to people’s safety. For example, we found a number of windows above ground floor level did not have restrictors fitted. We have asked the provider to tell us what they are going to make sure the premises are safe and adequately maintained.

Effective -

People had an individual care plan which set out their care needs. We found people and/or their representatives were involved in the assessment and planning of their health and care needs. This meant people could be assured their individual care needs and wishes were identified and planned for.

The home had good working relationships with other healthcare professionals and worked closely with them to make sure people’s needs were met. The input of other healthcare professionals involved in people's care and treatment was clearly recorded in their care records.

Caring –

The people we spoke told us the staff were “kind, caring and friendly”. One person said “staff work hard, are kind and look after us all”. Regular visitors to the service told us the staff were very “patient” when dealing with people who were confused or disorientated.

We found the care staff we spoke with demonstrated a good knowledge of people’s needs and were able to explain how individuals preferred their care and support to be delivered.

We found the atmosphere within the home was warm and friendly and we saw staff approached individual people in a way which showed they knew the person well and knew how best to assist them.

Responsive –

People’s needs were assessed before they moved into the home. We saw people’s care records had information about people’s individual needs and preferences. We found people had appropriate equipment to support them to meet their needs and/or maintain their independence.

People had access to a range of activities and were consulted about the types of activities they wanted to take part in.

Well led –

People told us they had confidence in the manager and they were approachable and listened to what they had to say. We saw the home held meetings for people who used the service and/or their representatives to give them the opportunity to share their views and make suggestions for improvements to the service.

The staff we spoke with said they enjoyed working at the home. They said they worked well as a team and felt supported by the manager.

However, we found the service did not have an effective system in place to identify, assess and manage risk. We have asked the provider to tell us what they are going to do to make sure they have an effective process in place to identity, assess and manage risks to the safety and welfare of people who use the service and others.

During the inspection we spoke with two people who used the service and two people’s relatives. We found people were satisfied with the care and support provided.

One person who used the service said “I can go into my bedroom whenever I want to. I’m all right here. The staff are pleasant”. Another said “I get up about half past eight but I can go back to bed whenever I want. I like my bedroom. It’s a nice big room. We have a bingo day and the activity coordinator is very good”.

One person’s relative told us they were involved in planning their relatives care. They said “I know all the staff; they are very friendly and helpful. They understand my relative’s condition and how to handle this. There’s not much change of staff. It’s a stable staff. I can go home relaxed because I know (my relative) is safe and well looked after”.

We found people’s needs were assessed and care was planned and delivered in a way that was intended to ensure people’s safety and wellbeing.

We found people were provided with a varied and nutritious diet.

We found people were cared for in clean and hygienic environment.

We found there were usually enough qualified, skilled and experienced staff to meet people’s needs. However, one person who used the service said they thought they were sometimes short of staff which meant they had to wait for help.

People were protected from the risk of receiving inappropriate or unsafe care because records were managed appropriately.

We spoke with seven people who used the service and they told us they enjoyed living at the home and were very complementary about the care and support provided by the manager and staff. Comments included: "The home is clean and comfortable, the food is very good and all the staff are kind and caring" and "I would obviously like to live at home but I know that is unrealistic so I am feel pleased to have found a nursing home were the staff are genuinely kind and helpful."

We reviewed the care files of three people who used the service and found procedures were in place to ensure that consent was gained from the person or their representative in relation to the care, support and treatment provided. We saw care plans clearly identified the needs of the person and included information on how they wished their care to be delivered.

We spoke with six visitors and they told us they had no concerns at all about the standard of care their relatives received. One person said "The staff help my relative without being intrusive". Another person said "I have no doubt at all that people are well cared for, I have every confidence in the manager and staff."

We spoke with one qualified nurse and five care staff and they told us there were clear lines of communication and accountability within the home. They told us they were supported by management to carry out their roles effectively through a planned programme of supervision, appraisals and training.

People who were able told us that they could make choices and decisions about how they wanted to spend time at the home and staff encourage them to be fully involved in their care and treatment. They also told us that they were pleased with the standard of care and support provided and that staff were kind, considerate and caring.