Archived: Ashberry Court

Updated 23 November 2015

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.’

This inspection which took place on 22 and 24 September 2015 and was unannounced.

The last inspection took place in June 2013 where no concerns were identified.

The inspection team consisted of two inspectors.

Before the inspection we looked at information provided by the local authority. We reviewed records held by the CQC including notifications. A notification is information about important events which the provider is required by law to tell us about. We also looked at information we hold about the service including previous reports, safeguarding notifications and investigations, and any other information that has been shared with us.

A Provider Information Return (PIR) had not yet been requested as the inspection had been bought forward due to concerns raised with CQC. The PIR is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make.

Not everyone living at Ashberry Court was able to tell us about their experiences of living at the home. We carried out observations in communal areas, case tracked three peoples care documentation in full and looked at specific care documentation for a further three people. This included risk assessments and associated daily records, charts, Medicine Administration Records (MAR) charts and medicine records. We read diary entries and handover information completed by staff, policies and procedures, accidents, incidents, quality assurance records, staff meeting minutes, maintenance and emergency plans. Recruitment files were reviewed for three staff and records of staff training for all staff.

We spoke with five people using the service and seven staff. This included the registered manager, care staff, kitchen staff and other staff members involved in the day to day running of the service.

There were no relatives or personal visitors to the home during our inspection. However, we spoke to a visiting nursing professional during the inspection. And a further two visiting professionals after the inspection.

Updated 23 November 2015

Ashberry Court is registered to provide permanent and respite care for up to 22 older people. There were 13 people living at the home at the time of the inspection. People required a range of help and support in relation to living with dementia and personal care needs.

There was a passenger lift at the home, due to the layout of the building, which included some split levels; a chair lift was in place to rooms which could not be accessed by the passenger lift.

This was an unannounced inspection which took place on 22 and 24 September 2015.

Ashberry Court had a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The manager was in day to day charge of the home. People and staff told us that they felt supported by the manager and told us they were always available on call to support them when needed.

The provider had not ensured that audits and systems had been maintained to ensure that quality and safety issues were identified and responded in a timely manner.

Environmental risk assessments had not been completed. This included fire and legionella checks.

Fire evacuation procedures needed to be improved to incorporate different staffing levels at night. Personal evacuation procedure information was not in place in event of an emergency evacuation.

Documentation needed to be improved this included identifying people’s choice and involvement in decisions, for example bathing and showering. We also found documentation for medicines needed to be improved.

Peoples dignity had not always been maintained, we saw that when people had spilt food down their clothes they had not been supported to change.

Daily charts including repositioning and nutritional charts had not been completed accurately to ensure peoples skin integrity and nutritional intake was safely monitored. This meant it was not clear that people received appropriate care too meet their needs.

Staff had not received appropriate training to support the needs of people living in the home. Supervisions and appraisals had not been completed. This meant that staff did not receive guidance to ensure they were suitably trained and supported to meet the needs of people living in the home.

Notifications had not been completed to inform CQC and other outside organisations when notifiable events occurred.

Recruitment checks were completed before staff began work.

Staff demonstrated a clear understanding on how to recognise and report abuse.

Referrals were made appropriately to outside agencies when required. For example GP appointments, dental appointments and hospital visits.

Feedback was gained from people this included questionnaires.

We found breaches of Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what actions we told the provider to take at the back of the full version of the report.