Ashingdon Hall

Updated 14 February 2024

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 completed by 3 inspectors 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

Ashingdon 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. Ashingdon Hall 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 provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was not a registered manager in post. A manager had been in post for 6 months and had submitted an application to register. We are currently assessing this application.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 4 December 2023 and ended on 18 December 2023. We visited the service on 4 and 7 December 2023.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the Local Authority and professionals who work with the service. 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 9 people who use the service and 9 relatives about their experience of Ashingdon Hall. We spoke with the manager, deputy manager, 1 senior member of staff and 7 members of staff. We reviewed a range of records. This included people’s care records and people’s medication administration records. We looked at 6 staff files in relation to recruitment, training, induction and supervision. A variety of records relating to the management of the service, quality assurance information and policies and procedures were viewed.

Updated 14 February 2024

About the service

Ashingdon Hall is a residential care home providing the regulated activity of accommodation and personal care to up to 28 people. The service provides support to older people and people living with dementia. At the time of our inspection there were 6 people living on the Residential Suite and 8 people living on the Dementia Suite.

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

Not all risks to people's safety and wellbeing were identified and recorded. Where these were recorded there was not enough detail as to how the risks posed should be mitigated. Personal Emergency Evacuation Plans were not sufficiently detailed and contained inaccurate information. The provider’s processes and procedures to protect people from abuse was not robust. Suitable arrangements were not in place to safeguard people’s financial arrangements. People were not always protected by the prevention and control of infection.

The key requirements of the Mental Capacity Act 2005 [MCA] and Deprivation of Liberty Safeguards [DoLS] were not being followed. People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. Not all staff employed at the service had attained up to date mandatory or specialist training relating to the needs of the people they supported. Newly employed staff had not received a formal induction or supervision. We could not be assured all people using the service had a sufficient fluid intake to maintain their hydration needs.

People’s privacy and dignity was not always promoted and respected. Not all care plans were up-to-date or reflective of people's current care needs. People using the service and their relatives were not involved in developing their care plan. Where people were at the end of their life, care plans did not reflect their individual preferences and wishes relating to how they would like their care to be delivered. We did not see enough evidence of how the Accessible Information Standard [AIS] had been applied to meet peoples’ communication needs. People were not routinely supported to engage in social activities. The provider’s arrangements to manage concerns and complaints were not robust.

The leadership, management and governance arrangements did not provide assurance the service was well-led. Governance and quality assurance arrangements were not reliable or effective in identifying shortfalls in the service. There was no robust audit and governance arrangements in place to effectively monitor the service. Not all conditions imposed on the provider’s registration were complied with. There was little evidence of sustained improvement and learning from events to improve the service and make the required improvements.

Staff felt supported and valued. Sufficient staff were deployed to meet people's care and support needs. Appropriate checks were completed before a new member of staff started working at the service. People were supported to receive their medicines safely. People were supported to access healthcare services and support as needed. People felt supported and treated with care and kindness. Arrangements were now in place for gathering relatives’ views about the quality of service provided.

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 inadequate (Published August 2023)

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 the provider remained in breach of regulations.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement and Recommendations

We have identified breaches in relation to safeguarding people from abuse, the management of risk, staff training, induction and supervision, consent, dignity and respect and governance at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The overall rating for this service is ‘Inadequate’ and the service therefore remains in ‘special measures.’ This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions of their registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it, and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.