Archived: Ashwood Lodge Care Home

Updated 2 March 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 Care Act 2014.

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

2 inspectors carried out this inspection.

Service and service type

Ashwood Lodge Care Home 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. Ashwood Lodge Care Home 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.

The registered manager had recently left the home. The provider had employed the services of a management consultancy firm to support in the running of the service and the closure.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 18 January 2023 and ended on 27 January 2023. We visited the home on 18 and 25 January 2023.

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 and professionals 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 6 people about their experience of the care provided. We spoke with 12 members of staff including the interim manager, the managing director of the consultancy firm, 3 seniors, a cook, 5 care staff and the nominated individual.

The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We looked at the care records of 4 people, a sample of medicines records and other records related to the management of the home.

Updated 2 March 2023

About the service

Ashwood Lodge Care Home is a residential care home that provides accommodation and personal care for up to 25 people. Some of the people were living with dementia. At the time of our inspection there were 18 people using the service.

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

The provider had taken the decision to close the home. The communication of the intended closure of the home was badly managed. People and staff told us they did not know what was happening and had been given very little information.

The home was not well maintained, which meant it was difficult to sustain infection prevention and control (IPC) measures. Adequate plans to keep people safe in the event of a fire were not in place. The Fire Service had recently inspected the home and found a number of safety issues which resulted in an enforcement notice being issued. The provider had implemented an agreed action plan to reduce the risks.

The management of people’s weight loss was not effective. Food required to support people with a fortified diet was not readily available. Malnutritional universal screening tool (MUST) were not used to assess people's needs in relation to diet and maintaining a healthy weight.

Medicine management was unsafe. Contingency plans had not been put in place for the re-ordering of medicines. Protocols for PRN ‘when required’ medicines were not always in place or lacked detail.

Permanent staff were recruited safely. The home did not have safe procedures for the use of agency staff. Protocols for checking the identity of agency staff and the completion of an induction was not in place.

The provider did not have robust quality assurance processes. Systems were in place to investigate safeguarding matters. Staff had completed safeguarding training.

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.

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 good (published 16 September 2019).

Why we inspected

We received concerns in relation to people’s care and support. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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 has changed from good to inadequate based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe, and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

Due to the shortfalls found during the inspection the provider was requested to produce an action plan detailing what action and by when that they would address the issues identified.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment, the assessment and mitigation of risk and the management of the home.

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

Follow up

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.