Acorn Lodge - Surbiton

On this page

• 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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. This is the first assessment for this newly registered service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Good management oversight and on-going support for the staff team had mitigated the risks associated with closed cultures. Staff listened to concerns about safety and investigated and reported safety events. Any incidents and accidents taking place were investigated, recorded and reported as necessary to ensure people’s safety. Lessons were learnt to continually identify and embed good practice.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. People were engaged and involved in planning their care and the provider had helped them to access the healthcare services for support where they required it. A stable staff team and good team working practices made sure there was continuity of care, including when people’s health and care needs changed.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The service shared concerns quickly and appropriately. Systems and processes were in place to ensure that any safeguarding concern received were appropriately recorded, reported and investigated to keep people safe from avoidable harm. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. People seemed comfortable around staff and asked them for support when needed. Staff were cheerful and chatty with people when they wanted to talk.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Staff knew people well and the support they required when they became anxious or distressed. A staff member commented, “I calm down [a person] by talking to them. We say to [name of the person] 'It's ok, everything will be ok'. We reassure the person if they become anxious.”

The provider did not always detect and control potential risks in the care environment. They did not always make sure the facilities supported the delivery of safe care. A maintenance improvement plan was used by the provider to carry out works at the service that included general updates to the environment where people lived. However, during our visit we observed some loose cables in the communal area and a pile of discarded items in the garden which were a potential trip hazard to people. We shared these concerns with the provider which they addressed on the same day.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support and development. Regular supervisions and appraisals were carried out to monitor and assess staff’s performance and skills making sure they met people’s individual care needs. Safe staff recruitment procedures were followed by the provider. There was enough staff to support people to go out, including accessing the community when they wanted to interact and socialise with other people.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Staff had access to personal protective equipment (PPE) as necessary. We saw staff wearing gloves and disposing of them afterwards appropriately. People were reminded to wash their hands where they required such support.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff were trained and had their competence checked before they started supporting people with their medicines. Medicine Administration Records (MAR) showed that people received their medicines as prescribed, including their 'as required' medicines. Staff consulted the GP and mental health team if people refused to take their medicines.