Ashleigh Court Rest Home

Updated 23 June 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 carried out by two inspectors.

Service and service type

Ashleigh Court Rest Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement dependent on their registration with us. Ashleigh Court Rest 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 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 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 three people who used the service and three family members. We also used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We spoke to seven members of staff including the registered manager, nominated individual, deputy manager and care workers. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We reviewed a range of records during the inspection. This included two people's care records, risk assessments and medicine administration. We looked at two staff files, including recruitment, induction, training and supervision records. A variety of records relating to the management of the service, including audits, people’s feedback, policies and procedures were reviewed.

Updated 23 June 2022

About the service

Ashleigh Court Rest Home is a residential care home providing personal and nursing care up to up to 22 people. The service provides support to people 65 and over. At the time of our inspection there were 9 people using the service.

During this inspection we carried out a separate thematic probe, which asked questions of the provider, people and their relatives, about the quality of oral health care support and access to dentists, for people living in the care home. This was to follow up on the findings and recommendations from our national report on oral healthcare in care homes that was published in 2019 called ‘Smiling Matters’. We will publish a follow up report to the 2019 'Smiling Matters' report, with up to date findings and recommendations about oral health, in due course.

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

Systems in place to monitor medicines had not been effective in identifying the areas for improvement found at this inspection. There was a new management structure in the home which had driven improvements in the areas identified in our last inspection. People told us they were asked for their feedback on care. We saw that the provider had worked with other agencies.

People told us they felt safe living in the home however medicines were not always stored safely. Risks to people were identified and mitigated through comprehensive risk assessments. The staff team were experienced with a varying skill mix benefiting the complex needs of people. Infection control procedures were in place and all staff were aware of these. When incidents occurred, lessons were learned.

The staff team made every effort to know and understand each of the people living in the service. The staff and registered manager considered the service users equality, dignity and respected people. People’s views were actively sought by which were listened to and actioned.

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. People found the meals were nutritious and varied to their preferences.

The staff team were trained and skilled in relation to the needs of the people living there. People’s needs were detailed and care planned for. Care was personalised with a focus on the individual needs and goals of the service users. While no-one was receiving end of life care there were end of life care plans in place. The complaints and compliments procedure was displayed and discussed with people, all complaints had been responded to and actioned appropriately.

Rating at last inspection and update

The last rating for this service was requires improvement (published 10 May 2021).

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 improvements had been made and the provider was no longer in breach of regulation 9 (Person-centred Care) and regulation 11 (Need for Consent). We found the provider remained in breach of regulation 17 (Good Governance).

The last rating for this service was requires improvement (published 10 May 2021). The service remains rated requires improvement. This service has been rated requires improvement for the last four consecutive inspections.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 25 February 2021. Breaches of legal requirements were found. The provider completed an action plan and submitted a monthly report after the last inspection to show what they would do and by when to improve person-centred care, the need for consent and good governance.

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

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

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.

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 have identified a breach in relation to the oversight and governance of service delivery at this inspection. Please see the action we have told the provider to take at the end of this report.

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 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.