Archived: Ashbourne House - Bristol

Updated 26 July 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 one inspector

Service and service type

Ashbourne House is a ‘care home’. People in care homes receive accommodation and personal care as a single package under one contractual agreement dependent on their registration with us. Ashbourne House 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 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 information gathered as part of monitoring activity that took place on 28 February 2022 to help plan the inspection and inform our judgements. We used all this information to plan our inspection.

During the inspection

We 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 with a relative and one regular visitor to the home. We spoke with the registered manager and three members of staff. We reviewed records for three people in the home and looked at other documents such as training and supervision records.

Updated 26 July 2022

About the service

Ashbourne House - Bristol (referred to throughout report as Ashbourne House) is a residential care home providing personal care to up to 17 people. The service provides support to older people, some of whom are living with dementia. At the time of our inspection there were seven people using the service.

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

We found breaches of regulation during our inspection. People were not always supported to have maximum choice and control of their lives and the principles of the Mental Capacity Act (MCA) were not being followed consistently. Best interest decisions and applications for Deprivation of Liberty were not made for everyone that needed them. The environment of the home was not safe in all areas, as not all windows had restrictors in place, personal evacuation plans had limited information and the fire risk assessment had not been reviewed since being completed in March 2016. Quality and safety monitoring systems were not effective in identifying and acting on shortfalls.

People were supported by staff who were kind and caring and who knew people and their individual needs well. People were treated with dignity and respect. There were care plans in place to guide staff in providing the right support for people. Risk assessments were carried out in areas such as nutrition and tissue viability so that measures could be identified to keep the person safe.

Improvements had been made to the decoration of the home since our last inspection. Staff worked well with other health and social care professionals to ensure people’s health and wellbeing. Staff received training and supervision to support them in their roles and to care for people effectively.

Rating at last inspection and update

The last rating for this service was good (published 10 November 2017)

Why we inspected

We undertook this inspection as part of a random selection of services which have had a recent Direct Monitoring Approach (DMA) assessment where no further action was needed to seek assurance about this decision and to identify learning about the DMA process.

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.

We have found evidence that the provider needs to make improvements. Please see the safe, effective 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.

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 requires improvement based on the findings of this inspection.

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

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 breaches in relation to safety, the MCA and good governance.

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.

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