Archived: Ashleigh House

Updated 6 August 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was conducted by two inspectors and an Expert by Experience (ExE). An ExE is a person who has personal experience of using or caring for someone who uses this type of care service. The ExE who supported this inspection had experience of care of older people.

Service and service type

Ashleigh house is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Ashleigh House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was no registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with seven people about their experiences of the care provided. We spoke with seven members of staff, including the provider, the interim manager, care staff, the cook, temporary agency care staff and a domestic who completed cleaning at the home. We observed the care people received and reviewed a range of records. This included four people's care records and multiple medicines records. We looked at three staff files in relation to recruitment and support, and a range of records relating to the management of the service, including audits and checks and policies and procedures.

Updated 6 August 2022

About the service

Ashleigh House is a residential care home providing personal care for up to a maximum of 24 people. The service provides support to older people. At the time of our inspection there were 16 people using the service.

People’s experience of using this service and what we found

We carried out an unannounced comprehensive inspection of this service on 13 and 19 June 2019. A breach of legal requirements was found. The provider completed an action plan after the last inspection to show what they would do and by when, to improve good governance of the service.

We undertook this inspection to check they had followed their action plan and to confirm they now met legal requirements.

The quality and safety of the service had deteriorated since our last inspection which showed the provider was unable to make and sustain improvements to benefit people. The lack of provider and management level oversight meant previously demonstrated standards and regulatory compliance had not been maintained. The provider's systems and processes designed to identify shortfalls, and to drive improvement were not effective and had not identified the concerns we found.

Whilst people told us they felt safe, risks associated with people's care, staffing, and the environment, (including fire safety) were not consistently identified, assessed, and well-managed. This placed people at potential risk of harm. The prevention and control of infection was not always managed safely and in line with government guidance. The management of medicines required improvement. Safeguarding procedures had not always been followed to protect people from avoidable harm.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. Records were not always sufficiently clear to show if people had capacity or not. Information on how to manage specific decisions relating to people’s care was not clear.

Staff lacked knowledge in some areas demonstrating training was not always effective. People and relatives spoke highly of the regular staff who cared for them. Staff were caring in nature, but people’s privacy and dignity was not upheld consistently. People had access to health and social care professionals to help support their needs.

People's needs were assessed prior to moving into the home to help ensure these could be met. Care records did not always provide staff with the information they needed to deliver personalised, safe care, and some records contained conflicting, out of date information. Daily care records had not always been completed in sufficient detail to demonstrate people had received the care they needed to keep them safe and well. Whilst people had access to some social activities there were limited opportunities to take part in varied and meaningful activities. People said staff were caring and spoke positively of the support they received. There had been no recent complaints received by the service.

Staff felt supported in their roles and spoke positively of management. The manager acknowledged the areas of the service that required improvement and acknowledged they needed additional support to achieve this.

Rating at last inspection and update

The overall rating for the service has changed from Requires Improvement to Inadequate based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Ashleigh House on our website at www.cqc.org.uk.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We identified breaches in relation to people's safety, and governance of the service.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.