Asmall Hall

Updated 11 November 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

2 inspectors, 1 medicines inspector and 1 Expert by Experience undertook the 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

Asmall Hall 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. Asmall Hall 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 the inspection

Prior to the inspection we looked at the information we held about the service. This included feedback and statutory notifications, which the provider is required to send to us by law. We also asked for feedback from professionals about their views of the service. We checked whether Healthwatch had undertaken an inspection of the service. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 5 people who used the service and 3 relatives and we received feedback from 4 professionals. We toured the building and undertook observations in the communal areas. We spoke with 14 staff members. These included, housekeeping, maintenance, the chef, care staff, nurse associates and nurses. We also spoke with the registered manager. We reviewed a wide range of records. These included; 5 care files, 3 staff files, medicines records and associated documents, training and supervision records, audits and monitoring in relation to the operation and management of the service.

Updated 11 November 2022

About the service

Asmall Hall is a care home providing personal and nursing care for up to 56 people. At the time of the inspection 50 people were living in the service. The service has 2 units one of which supports people living with a dementia.

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

Environment and individual risks had been assessed, incident and accidents were investigated and good evidence of lessons learnt were seen. People told us they felt safe and systems were in place to act on allegations of abuse. Staff were recruited safely. We saw plenty of staff during the inspection. Where agency was being used we were told they were regular staff. Staff told us, and records confirmed, training had been undertaken. Medicines were managed safely in the service.

MCA and DoLS assessments had been completed, staff were observed asking permission before undertaking any activity. 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. Admission assessments had been undertaken, and we saw evidence of the involvement of professionals in people’s care.

People received good care, their choices and likes were considered. Staff understood how to meet people’s needs. Policies and guidance was available to support good care delivery. The registered manager told us about the actions taken to investigate and address comments made in relation to people’s choice of staff member and the care provided.

Care plans had been developed recording people’s individual needs, including their communication needs. The registered manager took immediate action to ensure all records were up to date and reviewed. People’s end of life care needs were considered, where appropriate. Evidence of activities provided were recorded however, not all people were noted to have access to activities during the inspection. A system was in place to manage complaints, positive feedback was seen. Wi-Fi was available in the service.

We received very positive feedback about the registered manager and all of the staff team. We saw evidence of meetings taking place and surveys from people and professionals. Information was available on the actions taken from ‘you said we did’. A range of audits and monitoring was taking place. This included the findings and actions taken as a result. The provider had developed a detailed electronic system which supported the monitoring and oversight of the service.

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 24 January 2020). 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 regulations.

At our last inspection we made recommendations about the management and oversight of safe staff recruitment as well as the management and oversight of the service. At this inspection we found the provider had made improvements.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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 Asmall Hall on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.