Background to this inspection
Updated
20 November 2021
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 Care Act 2014.
This was a focussed inspection to check whether the provider had met the requirements of the requirement notice in relation to Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
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 an inspector and an Expert by Experience. 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
Ashbourne House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
The service had a manager who had recently registered with the Care Quality Commission. 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.
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 and gathered feedback from the local authority. We reviewed the inspection report and action plan from our last inspection. The provider was not asked to complete a provider information return prior to this inspection. This is information providers are required to send us with key information about the service, what it does well and improvements they plan to make. We took this into account in making our judgements in this report. We used all of this information to plan our inspection.
During the inspection
During the inspection we looked at a variety of records, including three people’s care files, a sample of medicines records and two staff recruitment files. We also looked at records relating to the management of the service, including policies, audits and action plans. We spoke with the registered manager, three senior carers and a care assistant. We talked to one person who lived at the home. The Expert by Experience spoke with ten relatives on the telephone.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We looked at several other documents, including training and supervision records, policies and staff rotas
Updated
20 November 2021
About the service
Ashbourne House is a residential care home which provides accommodation and personal care for up to 35 people. At the time of the inspection 25 people lived at the service. The accommodation is provided in one building with bedrooms across two floors and communal areas on the ground floor.
People’s experience of using this service and what we found
Relatives spoke positively about the home and the care and support provided by staff. They told us they felt their loved ones were safe living at Ashbourne House. The recruitment process was robust and there were enough staff to care for people safely. Medicines were managed correctly. A minor issue with medicines records was brought to the attention of the registered manager during the inspection and dealt with promptly.
Infection control practices were in place and the home was generally clean. However, we found the flooring and fittings of the downstairs shower room were in a poor condition and difficult to clean. The provider has agreed to refurbish the room within a specified time frame.
Since our last inspection there had been a change in the management of the home, with a new registered manager in post, who worked closely with the area manager. Staff spoke positively about the management team and were happy with changes that had been recently implemented. Staff told us they felt morale and team working had improved and that they felt valued and supported.
There had been an improvement in the quality assurance systems used to monitor the service. Relatives we spoke with were happy with the way the service communicated with them and kept them informed. Regular monthly contact with relatives had recently been introduced to ensure they had an provide an opportunity to discuss any concerns and to provide feedback.
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 14 June 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 regulations.
Why we inspected
We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.
The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection
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.
Follow up
We will review the service to ensure the refurbishment of the downstairs shower room is completed. We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.