Archived: Ashlee Lodge

Updated 29 May 2021

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 Care Act 2014.

This was a focussed inspection. It was undertaken to check whether the provider had met the requirements of the last inspection.

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 team consisted of one inspector.

Service and service type

Ashlee Lodge is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with the Care Quality Commission. 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.

Notice of inspection

We gave the service 24 hours’ notice of the inspection. This was because it is a small service and we needed to be sure that the provider or registered manager would be in the office to support the inspection.

What we did before the inspection

The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.

We reviewed the information we held about the service and the service provider, including the previous inspection report and the action plan supplied by the provider. We looked at notifications we had received for this service. We sought feedback from the local authority and professionals who work with the service. Notifications are information about important events the service is required to send us by law. We used all of this information to plan our inspection.

During the inspection-

We spoke with two people during the inspection. Most people were not able to share their views of the service, due to complex communication and support needs. Therefore, we observed their experiences living at Ashlee Lodge and staff interactions with them. We spoke with the registered manager, and three staff members.

We reviewed a range of records. This included two people’s care records and everyone’s medication records. We looked at specific areas of another person’s care records. We looked at two staff files in relation to recruitment. A variety of records relating to the management of the service, including audits, policies and procedures were also reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records. We received feedback by email from two health professionals and two people’s relatives.

Updated 29 May 2021

About the service

Ashlee Lodge is a residential care home providing accommodation and personal care for up to five people. At the time of inspection, five people were living at the service. People living at Ashlee Lodge had learning disabilities and some associated physical and/or sensory disabilities. Some people had complex communication needs and required staff who knew them well to meet their needs.

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

Quality and governance systems had improved however they had not been fully established and embedded into everyday practice. The service was in the process of introducing a new electronic system for recording all records. This was a slow process so there were two systems operating at the same time. However, the registered manager was clear about the areas that still required reviewing and updating. Records in relation to some aspects of people’s mental capacity and demonstrating how people spent their day were not detailed. There were interim measures to support two people with activities outside of the home, but these were only one day a week.

People were protected from the risks of harm, abuse or discrimination because staff knew what actions to take if they identified concerns. The home was clean and tidy throughout. Enhanced cleaning had been instigated as a result of the pandemic, staff had received additional training and the home had a visiting procedure that was thorough to ensure as far as possible people’s safety from the virus.

There were enough staff working to provide the support people needed. Recruitment procedures ensured only suitable staff worked at the service. There were safe procedures to ensure people received their medicines as prescribed. Relatives and professionals spoke positively of the care provided by staff.

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

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right Support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

This service was able to demonstrate how they were meeting how they were meeting the underpinning principles of Right support, right care, right culture.

Right support:

¿ Two people displayed behaviours that made support in public difficult during the pandemic. There was a shortage of staff who could drive so this had a temporary restriction on the numbers and frequency of outings they could have. An interim arrangement had been made to try to address this and a new staff member had just been appointed. Staff spent time with people individually to assess their wishes in relation to decoration of communal areas and these were then voted on. The sensory room had been redecorated to ensure people had an additional area other than the lounge to spend quiet time away from others.

Right care:

¿ Care plans provided guidance to ensure staff could care for people in a way that suited their individual needs and wishes. Greater analysis of links between people’s health and behaviours had been introduced. Although still at an early stage, this had already helped staff to focus their support in meeting one person’s health needs appropriately which then resulted in a reduction in behaviours that challenged. We observed that staff were caring in their approach and people were very content in their surroundings.

Right culture:

¿ One person who used to spend a lot of time in their bedroom now chose to spend time in the lounge with others. Staff saw this as a sign that they were happy. Staff told us that the registered manager was approachable and easy to speak with and there were regular opportunities to share their views on the running of the home either in individual supervision or at staff meetings. A pictorial staff rota was displayed to show staff which staff were on duty each day and a pictorial menu board was being devised to enable people to have a greater say in food choices.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 22 August 2019). At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 21 June 2019. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve in relation to safe care and treatment and good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions safe care and treatment and Well-led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

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

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.