Archived: Ashfield (Malton)

Updated 26 May 2023

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

An Inspector and an Expert by Experience undertook this inspection. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Ashfield (Malton) 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. Ashfield (Malton) 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 provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed the information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service, including Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. 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 of this information to plan our inspection.

During the inspection

We spoke with 6 people who use the service and 6 relatives about their experience of the care provided. We spoke with 8 staff members including the interim service manager, the registered manager, the deputy manager, senior care and care workers, cleaners and the cook.

We reviewed a range of records. This included three people’s care records and multiple medication records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at quality assurance records.

Updated 26 May 2023

About the service

Ashfield (Malton) is a residential care home providing personal and nursing care to up to 31 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

A governance framework was in place however this was not robust as it failed to identify the concerns we found during inspection. There was a lack of consistency and discrepancies in documentation relating to some aspects of the service. Quality assurance information to support and evaluate learning and improvement had commenced but was not yet fully embedded. The registered manager and deputy manager had started to review and allocate responsibilities.

Detailed risk assessments meant risks to people were monitored and managed, however on the day of our visit the number of personal emergency evacuation plans (PEEPs) did not match the number of people living at the home because 1 person had been admitted to hospital that week.

Staff were knowledgeable about how to keep people safe and felt confident to report concerns to seniors and managers should they arise. Sufficient numbers of suitable staff were employed, and care was observed to be unhurried. Medicines were administered safely, and current guidelines and protocols were followed. People were protected by the prevention and control of infection. The home was clean, tidy and odour-free.

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 did not support this practice. This is because Deprivation of Liberty Safeguards had sometimes been made when it was recorded the person had capacity.

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 8 April 2022). The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found the provider remained in breach of regulations.

Why we inspected

We carried out an unannounced focused inspection of this service on 25 and 31 January and 4 February 2022. 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 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 and Well-led which contain those requirements. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service remains the same. This is based on the findings at this inspection.

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

Enforcement

We have identified breaches in relation to how managers tracked and monitored risk and used quality assurance audits to ensure systems and processes were followed correctly at this inspection.

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

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.