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CQC report explained · a residential care home, run by Bloomcare

Acacia Court

17-19, Roe Lane, Southport, PR9 9EB

Goodpublished 2 February 2024, 2 years ago

Rated Good: inspectors found the service performing well and meeting their expectations.

The five questions inspectors ask
Safe?
Good
Risks were assessed and staff knew how to keep people safe. Medicines were managed safely overall, but some care records and instructions for medicines given when needed were not detailed enough.
Effective?
Good
People received support with their dietary needs, consent and healthcare. The environment was not fully designed for people living with dementia, but an action plan for improvements was underway.
Caring?
Good
Inspectors found a strong person-centred culture, kind interactions and support that protected people's privacy, dignity and independence.
Responsive?
Good
Care was personalised and staff knew people's preferences. There was no structured activities plan at the start of the inspection, but one was put in place before the inspection ended.
Well-led?
Requires improvement
The home had quality monitoring systems, but they did not always identify missing care information, incomplete medicines protocols or gaps in safety checks. Incident trends were not always analysed thoroughly and some CQC notifications were delayed.
The latest report, explained

What inspectors found, February 2024

Rated Good overall; inspectors found kind, safe care, but leadership and quality checks require improvement.

Inspectors visited the home without giving notice on 20 December 2023 and 3 January 2024. They spoke with people, relatives and staff, observed care, and checked care records, medicines, recruitment files, audits and other records.

The home was rated Good for safe, effective, caring and responsive care. Inspectors found enough staff, safe medicines management overall, clean areas, suitable support with food and drink, person-centred care and kind interactions. Relatives were positive about the care their loved ones received.

The well-led rating was Requires Improvement. Some care records were incomplete, medicines instructions were not always detailed enough, and checks of incidents and the environment were not consistently robust. The manager took some action during the inspection, including updating records and putting an activities plan in place.

What inspectors praised

  • Safe staffing

    Inspectors found enough staff to meet people's needs. Staff were visible and available when people needed support.

    “Overall, staff were safely recruited and deployed in sufficient numbers to meet people's needs.” from the report

  • Kind and respectful care

    Staff were caring and supported people's dignity, privacy, independence and communication needs.

    “Our observations found staff were caring in their approach, and we observed several kind interactions between people and staff throughout the inspection.” from the report

  • Personalised support

    Care plans considered people's whole-life needs, and staff knew people's likes, dislikes and preferences.

    “Detailed care plans were in place that considered people's whole life needs and staff knew people well including their likes, dislikes and preferences.” from the report

  • Clean environment

    Shared areas and bedrooms were clean and hygienic. Staff used protective equipment appropriately.

    “The communal areas of the home and people's bedrooms were clean and hygienic.” from the report
What inspectors were concerned about

  • Incident learning

    needs fixing

    The manager reviewed individual incidents but did not always look thoroughly at wider patterns and trends. This could mean missed opportunities to reduce repeat incidents.

    “However, a robust analysis of incident trends did not always take place.” from the report

  • Incomplete care and medicines records

    needs fixing

    Some care records were missing information, and instructions for medicines given when needed were not always detailed enough to guide staff. The manager updated some records and protocols during the inspection.

    “However, there was some missing information in people's care records and the lack of detailed protocols for 'as and when required' medicines had not been identified.” from the report

  • Missed safety checks

    needs fixing

    The manager was expected to complete daily checks around the home, but records showed these happened only twice in December 2023. The manager committed to completing them daily.

    “However, records showed only two checks took place in December 2023 and this meant opportunities to identify hazards were missed.” from the report

  • Delayed notifications

    needs fixing

    Some required notifications to CQC were submitted late. This was part of the wider leadership and governance concern.

    “However, we found there was a delay in submitting some notifications to the commission.” from the report

  • Dementia-friendly design

    minor

    The building was not yet fully designed for people living with dementia. An external survey had been completed and an improvement plan was underway.

    “The environment was not fully designed to meet the needs of people living with dementia.” from the report
Questions to ask them, based on this report
  1. 01What changes have been made to analyse accident and incident patterns, and how will you check that these changes reduce repeat incidents?
  2. 02How do you now make sure care records include all the measures needed to manage each person's risks?
  3. 03How are instructions for medicines given when needed kept detailed and up to date?
  4. 04Are the daily checks of the home now being completed and recorded every day?
  5. 05What improvements have been made to the environment for people living with dementia, and what work remains?

This was an unannounced first inspection of the newly registered service, covering all five CQC questions, the care provided and the premises, including infection prevention and control. This explanation was written from the published report of 2 February 2024 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.

The story over the years

Every inspection of Acacia Court

7 rated inspections over 8 years: the service has improved, from Inadequate to Good.

  1. February 2024Goodcurrent rating
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement

    Read what inspectors found at Acacia Court →

  2. January 2021Inspected but not rated
    Safe: Inspected but not rated
  3. November 2018Goodup from Requires improvement
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
  4. May 2018Requires improvementstayed Requires improvement
    Safe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
  5. October 2017Requires improvementstayed Requires improvement
    Safe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
  6. January 2017Requires improvementstayed Requires improvement
    Safe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
  7. July 2016Requires improvementup from Inadequate
    Safe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
  8. February 2016Inadequate
    Safe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
  9. August 2021

    Registered with the Care Quality Commission on 18 August 2021.

Ratings and report dates from the Care Quality Commission. A service can also be visited without a new rating being published, so the timeline shows published inspections, not every contact the CQC has had with the service.

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