Ash Lodge Care Home with Nursing

Updated 11 July 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

The inspection was carried out by one inspector, one specialist advisor who was a nurse and an Expert by Experience. 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

Ash Lodge Care Home with Nursing is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. Ash Lodge is a care home with 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 a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service. 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. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We spoke with five people who used the service and sixteen relatives about their experience of the care provided. We spoke with one visiting healthcare professional, six members of staff including the registered manager, deputy manager, senior care staff and care workers.

We reviewed a range of records. This included eight people's care records, quality assurance 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, including policies and procedures were reviewed.

We continued to seek clarification from the provider to validate evidence found, including information about the provider's deprivation of liberty protection safeguards referrals and renewal documentation.

Updated 11 July 2023

About the service

Ash Lodge Care Home with Nursing is a care home providing personal care and accommodation to up to seventy people. The service provides support to older people and people with dementia. At the time of our inspection there were sixty four people using the service.

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

The provider was not consistently working in line with the principles of the Mental Capacity Act which put people at risk of being deprived of their liberty without lawful authority. Care records showed some people who had been identified as lacking capacity had missing information on capacity assessments and best interest decisions.

The provider had safeguarding systems and processes to keep people safe. Staff knew about the risks to people and followed the assessments to ensure they met people's needs.

People received their medicines safely and as prescribed and were supported by sufficient numbers of staff to ensure risk of harm was minimised.

Staff sought people's consent before providing care and support. People's individual communication needs were considered to support them to be involved in their care.

Staff spoke positively about working for the provider. They felt well supported and that they could talk to the management team at any time, feeling confident any concerns would be acted on promptly. They felt valued and happy in their role.

Staff had been recruited appropriately and had received relevant training, so they were able to support people with their individual care and support needs.

People felt safe and were supported by staff who knew how to protect them from avoidable harm.

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

Rating at last inspection

The last rating for the service was good (published on 21 February 2018).

Why we inspected

This inspection was prompted by a review of the information we held about this service. A decision was made for us to inspect and examine the information we had reviewed. As a result, we undertook a comprehensive 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.

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

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

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

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will meet with the provider following this report being published to discuss how changes will be implemented. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.