Acorns Health Care

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We assessed 4 quality statements in the safe key question and found areas of concern. We found there was a lack of clear understanding and knowledge with the Mental Capacity Act 2005, including where appropriate the use of the Mental Capacity Act 2005 Deprivation of Liberty Safeguards, to ensure people’s human rights were fully supported and upheld. This meant people were at an increased risk of being subject to acts intended to control or restrain them which were not necessary to prevent, or not a proportionate response to, a risk of harm. This has resulted in a breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more detail of our concerns in the evidence category findings below.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People we spoke with told us they felt safe in their homes. One person told us, “Very happy here.” People and relatives told us they had opportunities to feedback to the provider and to raise concerns. They felt the provider was approachable and they were encouraged to raise concerns and discuss incidents. One relative told us, “If he thinks something isn’t right, he phones management himself and reports it.” However, feedback from relatives was mixed as to whether they felt the provider was always effective in how they dealt with concerns and incidents and used them as an opportunity to put things right, learn and improve. One relative told us about an area for improvement they had identified and how they felt they had had to raise it more than once before the provider took action to address it. Some relatives told us they were kept informed about incidents and the action taken in response. Comments from relatives included, “They phone me straight away if there are any incidents. They are Tip Top” and “If anything happened, they follow the procedures to the line.” However, other relatives told us that they did not always feel they were listened to in a timely way and communication was not always effective. Comments from relatives included, “Sometimes they don’t take on board or respond quickly” and “If I raise something and don’t get a response, it’s frustrating. Waiting for 2 days to get a response.” The provider told us responding within 48 hours is within their acceptable timeframes to respond to contact and that they had systems in place to monitor this.

The senior leadership team told us they were passionate about having an open culture with a focus on transparency, openness and learning. Staff told us they felt this culture was in place and felt comfortable raising concerns. The senior leadership team told us how they were able to have oversight over all accidents, incidents and complaints and reviewed them regularly. They enabled staff to develop their confidence and knowledge in managing these events whilst ensuring appropriate actions had been taken and lessons learnt identified. Staff mostly told us they were provided opportunities to share ideas, concerns and learning from incidents with de-briefs, meetings (both in groups and on their own) and reviews. They mostly felt feedback about action taken was shared and they were kept informed. Staff mostly told us they felt listened to and felt risks were responded to. One staff member told us, “They are always constantly giving feedback. We get feedback on anything, and they are also concerned if the staff are ok after any incident and if the service user is ok as well after.” However, not all staff felt the communication was effective following incidents and action taken to manage risk. Some staff told us they felt communication could be improved as they did not feel they consistently got feedback and at times felt they would have to seek out whether there had been any changes or updates they needed to be aware of. Staff were able to share examples of action that had been taken in response to incidents to manage risk. Some staff gave examples where they had changed people’s risk assessments following an incident where restrictive practices were imposed. They could not clearly demonstrate their understanding and compliance with relevant legislation to ensure people’s rights were protected and upheld. We found there was inconsistent knowledge across the staff in most roles in relation to mental capacity and best interests.

We received mixed feedback from professionals involved in the service. Some of the feedback was exceptionally positive about the culture of the provider and how risks were effectively managed. They felt the provider was open and transparent and wanted to work in partnership to achieve the best outcomes for people. They told us the provider engaged in continuous learning which was specific to each person and there was a culture of positive risk taking where people were supported to maximise opportunities to promote their independence, improve their quality of life and be in control of their care. However, some professionals were concerned about some of the restrictive practices in place and whether they were the least restrictive approaches for people and used for the least amount of time possible. They were concerned lessons learnt from incidents were not always as robust as they could have been and did not always reduce the risk of recurrence. They felt the provider did not always ensure records about incidents had enough detail to enable effective analysis and learning. Although there was an acknowledgement from professionals that the provider shared their records relating to incidents with them consistently, they felt the provider did not always provide robust responses for them to be fully assured people were supported in the safest, most proportionate and appropriate way. They felt this was an area the provider could improve in. Some professionals felt the provider was not always receptive to exploring assistive technology to promote people’s independence and reduce the level of support required from staff. We spoke to the provider about this who felt they engaged in honest discussion with commissioners and were open about changes in people’s support needs where they had reduced or increased, including the reduction in frequency and length of time of incidents they had supported, and had implemented assistive technology where it had not compromised care.

The provider had an effective reporting procedure and system in place to ensure all relevant persons were notified of any incidents or accidents promptly. It also enabled effective oversight as any actions taken and recorded could be reviewed by relevant persons remotely. The processes and systems in place supported a culture of safety and learning and evidenced how the provider was open and transparent about incidents. Analysis and learning were a key part of their processes and systems. The provider analysed incidents to identify potential themes, trends and patterns. They were able to evidence how they had used this information to identify potential triggers and implement proactive strategies to reduce risk of recurrence. However, we found there were inconsistencies across different households in the level of detail recorded in relation to learning identified from incidents and complaints. For example, some records where concerns had been identified did not identify what learning had been taken or how it would be implemented. The provider had identified this through their own quality assurance processes and was taking action in response which needed time to become embedded within the service. The provider had a process in place to record and review all complaints and the outcomes and learning identified. They had systems in place to share learning and outcomes across the organisation.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People we spoke with told us they felt safe when supported by staff and knew who to contact to raise safety concerns. One person told us when they felt unsafe, they were supported and reassured by staff. Relatives we spoke with told us they felt people were kept safe by the provider. Comments from relatives included, “I have never seen her unhappy. They have an open-door policy and I’m welcomed every time I go there”, “I feel that he is safe, and generally well cared for” and “I feel happy that he is safe. Makes choices, they do their upmost to make it happen.” Relatives we spoke with told us they felt the provider were open with other agencies and reported safeguarding incidents. One relative told us about 2 safeguarding incidents the provider had identified and reported to the local safeguarding adults team. They told us, “I was contacted by safeguarding and believe steps have been put in place to avoid this happening again.” We received mixed feedback about people being consistently supported appropriately to proactively support their emotional wellbeing and when they experienced emotional distress. Some relatives told us they felt less experienced staff were not always fully familiar with people’s preferences which had resulted in increased incidents of emotional distress for people. Comments included, “The quality of focused care seems to be down to the individual staff member. This can lead to an inconsistent approach when caring for our relative” and “It is my feeling that enough time is not spent for new staff to shadow before they are caring independently with those like [person] who have complex needs.”

Some people supported by the service had restrictions placed on them, including physical restraint, to ensure they remained safe. Where people could not consent to these restrictions, they needed to be agreed according to the principles of the Mental Capacity Act 2005 (MCA). We found there were staff in different roles across the organisation who were unable to demonstrate they understood the processes and practices they needed to follow to ensure people who lacked capacity to consent to their care had their human rights upheld. Although staff were able to describe the MCA, they were not always able to demonstrate how they applied it in their practice. Through our discussions with staff, we identified that they did not always display a clear understanding of what might be a restrictive practice. We were concerned that on occasions this had led them to fail to identify that approaches being used were restrictive in nature. There was a strong emphasis on training for staff and leaders which included ensuring staff had a strong understanding of safeguarding and how to take appropriate action. This was demonstrated by staff who were consistently able to demonstrate their understanding of safeguarding, speaking up and the appropriate action to take in relation to safeguarding concerns. Leaders were clear on the processes and systems in place to ensure appropriate action was taken in a timely way to safeguard people and how they ensured all staff understood their responsibilities in relation to safeguarding. Leaders ensured people and staff had opportunities to raise any concerns and had a range of people they could speak to in confidence.

We observed people receiving safe care and support throughout the assessment. People appeared comfortable with staff and knew staff, including the senior leadership team. People had opportunities to talk in confidence, or in shared spaces, and we observed people being given the choice by staff. We observed people being supported to raise concerns, being listened to by staff and being appropriately supported to have their concerns responded to.

Staff and senior leaders were clear when people were restrained for their safety it was to be least restrictive and for the least amount of time possible. People had behaviour support plans in place that described proactive strategies to reduce the need for restrictive practices. Systems were in place to report and learn from any incidents where restrictive practices were used. However, staff and leaders were not able to evidence how it had been identified the restrictions and restraint detailed in people’s care plans were the least restrictive actions to be undertaken in each person’s best interests as they did not have the appropriate records in place. They were also not able to demonstrate or evidence who had been involved in identifying and agreeing the least restrictive approaches for people, how they had been determined to be in their best interests and whether there had been input from the appropriate professionals when making those decisions. This meant people were at an increased risk of being subject to acts intended to control or restrain them which were not necessary to prevent, or not a proportionate response to, a risk of harm. The provider was able to evidence how they ensured staff had a strong understanding of safeguarding and how they checked their knowledge regularly. The provider’s records evidenced they consistently reported safeguarding incidents to the relevant external organisations and worked in partnership to keep people safe.

People we spoke with told us staff supported them with their emotional wellbeing, mental health and their physical support needs. Where restrictions had been imposed on them, some people were able to describe some of the restrictions and their understanding of why they were in place. One person we spoke with demonstrated their awareness of the restrictions that had been imposed on them and could describe how they kept them safe from significant harm. They told us, “Restraint is used, but only as a last resort … and only for as long as needed until I feel calmer.” However, some relatives we spoke with told us they felt people were not always supported consistently to have their physical and emotional support needs met. People we spoke with told us they were involved in their care planning. Where people were unable to communicate their wishes or preferences in relation to their care planning, relatives confirmed they were involved. Relatives we spoke with told us they felt on the whole risks were managed by the provider for people and that there was a culture of positive risk taking which had increased people’s independence and improved their quality of life. For example, people had been supported to access new activities, develop independent living skills and increase their confidence. However, some relatives felt records relating to care lacked detail. One relative told us, “Record keeping appears haphazard and at times without sufficient detail.” The provider had an electronic care planning system which could be accessed by relatives where appropriate. They told us the format of the system may have meant some relatives only accessed the summary section of the records and that they had provided relatives with training on how to use their system to resolve this.

The provider embraced dynamic risk assessing which was reflected in the feedback from staff. People were supported by staff to utilise opportunities as they arose to develop their independent living skills, build their confidence and to try new experiences. One staff member told us, “There is a positive risk-taking culture and it is part of my job to keep that going.” Staff were able to share examples of how people had been supported to achieve their goals and aspirations through positive risk planning and had improved people’s quality of life. Staff were able to describe how they were able to recognise when people may need support with their emotional wellbeing and the proactive strategies in place which were personalised to the person. Staff knew people’s preferred communication methods and were able to detail how people made decisions and choices. Staff were able to describe in detail how they supported people to manage risks. Such as in relation to seizures, falls, supporting people when experiencing emotional distress and overcoming communication barriers.

We observed instances where people were supported to be involved in making daily decisions and to have those choices respected. For example, we observed people being supported to use their preferred communication methods to make choices about what they wanted to do, such as what activities they wanted to do or food and drink choices. We observed a person being supported to make an informed choice. We saw staff spending time supporting them to explore and discuss their choices and the risks and benefits of those choices. Staff provided reassurance about how the person could be supported to manage risks. The staff provided a supportive space for the person to share their concerns and discussed ways they could support them to manage their concerns in a positive way. People were supported by staff who knew them well and who were alert to their physical and emotional support needs. We saw examples of staff responding in a positive way to people who communicated their needs and emotional distress. Staff followed people’s personalised care plans and risk assessments to proactively support people and achieve positive outcomes.

Risk assessments were person-centred and regularly reviewed. The provider had implemented ‘trauma informed care’ in their approach to care. Trauma informed care takes a person-centred approach to people’s life experiences and aims to provide an environment where a person who has experienced trauma feels safe and can develop trust. This had resulted in people being supported with personalised approaches and coping strategies which reduced risks of people being re-traumatised. One staff member told us, “It is something we have always done, putting it into the care plans, when we induct staff, we do training on it about how we support staff and service users, using staff’s trauma to show them about people’s trauma, those who can’t communicate verbally will use body language to tell you about their trauma ... A lot of the time, because we know of their past trauma’s we know how they act because of those.” We saw evidence of people and relatives being involved in care planning and reviews. Following our feedback that not everyone's risk assessment relating to weighted blankets had enough detail, the provider was working on ensuring people’s risk assessments relating to the use of ‘weighted blankets’ were updated to provide comprehensive information to staff. There was a culture of positive risk taking within the service which was supported by the provider’s processes and systems. This enabled a balanced and proportionate approach to risk that improved people’s quality of life.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

People we spoke with were mostly positive about the care they received from staff. People told us they felt staff knew how they wanted to be supported and felt comfortable being supported by their staff team. People told us about shared interests they had with staff and that they were able to spend time chatting with staff about whatever they wanted to. People confirmed they did not feel rushed by staff or that staff were task focussed. People confirmed they had staff when they expected them to. One person told us sometimes their additional support to access the community wasn’t available and if a manager was not able to support them then they would have the time back on another day. Relatives confirmed there were enough staff. Comments included, “Oh yes, there’s loads of them. 24/7 at least 2 staff a day. Even in the evenings”, “He has a good 3 to 4 core staff that are consistent” and “He has enough staff to cover him 2:1 day and night.” There was a consensus from relatives that people had bespoke staff teams around them and their likes, preferences and support needs were understood. Comments from relatives included, “The staff are handpicked for her needs. She likes bubbly, smiley people, and that’s what she’s got”, “They change the staff to suit his appointments”, “They are just amazing. They do everything. I can’t thank them enough” and “They all work together. He loves them. Loves life.” One relative told us how they had been involved in delivering training to staff about their loved one’s individualised needs. They had worked with the provider to share training videos they had developed.

Staff told us there were enough staff to support people’s needs and there were effective arrangements in place to cover staff absences. One staff member told us, “There are never times where we work short staffed. I think this is the only company I have ever worked for that isn’t short staffed.” Most staff told us they had regular supervisions and also had specific wellbeing supervisions which focused on what support they may need. For managers, the provider told us they had an arrangement in place where their supervisions were held with an external professional, managers were positive about this support. Staff were very positive about the induction they received from the provider. They told us it was in-depth and specific to the households they were working in. One staff member told us, “Before I actually started I had a week long induction in Southampton where they put us through everything about the company, and about people we support ... It gave me a good idea of who the people were and what their support needs were even before I stepped in.” Most staff were extremely positive about the training provided to them. Comments included, “We have had training on mental health and dealing with mental stress. We have a refresher course every few months on this. We have in person training on how to use physical restraint and we go through scenarios on using restraint. I feel confident that we can support the service users here” and “Emotional distress is one of the training courses we do.” Staff told us of the bespoke training videos a relative had created and how useful they were. Some staff who supported a person who used some Makaton told us they would like accredited training in Makaton symbols and signs to develop their understanding and use when communicating with this person. One staff member told us how they used social media videos on Makaton to learn and would practice with the person who enjoyed this.

We saw people had enough staff to support them. We observed staff having time to speak with people and have conversations beyond discussions about what immediate support needs they had. Staff were visible and responsive to people. People appeared comfortable with staff and knew them. Staff were familiar with people and understood people’s preferred communication methods. People were supported at their preferred pace and were not rushed by staff. Where people were able to do things for themselves, staff supported this, remaining engaged and working at the person’s pace.

There were appropriate staffing levels and skill mix to ensure people received support which met their needs. The senior leadership team had effective oversight over staffing needs and ensured staff were deployed effectively. The provider had implemented robust, in-depth induction procedures. There were people specific inductions and training which involved people and relatives where they wanted to be involved. The provider’s induction programme ensured staff had time to read people’s care planning documentation, receive the training they need to support people and had incorporated bespoke training to individuals to make the training even more relevant and useful for staff. Effective processes and systems were in place to ensure staff received support to meet people’s needs. Such as supervisions, spot checks, competencies, wellbeing supervisions and de-briefs. The provider had recruitment processes which were fair and ensured there was no disadvantage based on any specific protected characteristic. However, we found some staff files had some employment history gaps. The provider took prompt action to address this during the assessment.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.