22 and 24 September 2015
During a routine inspection
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.