Ashcroft House - Leeds

Updated 23 March 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.

Inspection team

The inspection team consisted of 2 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.

Ashcroft House - Leeds is a ‘care home.’ People in care homes receive accommodation and care as a single package under one contractual agreement dependent on their registration with us. Ashcroft House - Leeds provides personal 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 a registered manager in post.

Notice of inspection

The inspection was unannounced.

What we did before the inspection

We reviewed the information we had received about the service since the last 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 met with key stakeholders such as the local authority to fully understand their concerns and to include these in planning for our inspection.

During the inspection

We reviewed the care records for 6 people and multiple records relating to people’s medicines. A variety of records relating to the management of the service, including policies and procedures were also reviewed. We spoke with 5 people using the service and 3 relatives. We spoke with 9 staff including the registered manager, provider and care staff.

Updated 23 March 2024

About the service

Ashcroft House - Leeds is a care home providing personal care to a maximum of 32 people. The service provides support to older people, some of whom were living with dementia. At the time of our inspection there were 27 people using the service.

People’s experience of the service and what we found

People were not kept safe in the service. The provider did not always properly assess risks, and effective measures were not in place to mitigate identified risks. Actions were not always taken when incidents occurred to reduce the risk of recurrence.

Environmental risks had not always been identified, assessed, and mitigated. This placed people at risk of harm.

Care plans were unclear about how staff were to support people to reach and maintain a healthy weight. There was a lack of information about adequately monitoring people’s nutrition and promptly acting upon concerns.

There were insufficient staff to support people’s lifestyle choices. People were not supported to access the local community when they wished due to the lack of staff to enable this.

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.

The premises was not adapted or designed to meet the needs of people living with dementia. The environment was tired, poorly maintained, and did not meet people’s needs.

The provider had a poor history of compliance with this service. The need for improvements had been identified and shared with the provider at previous inspections, but they had failed to make and sustain the necessary improvements.

Whilst staff were kind and caring, failure to meet regulations and fundamental standards meant people have come to harm, received care that did not protect them from risks and have had their wellbeing compromised. This does not demonstrate a caring service.

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

Rating at last inspection

The last rating for this service was Requires Improvement (published 9 July 2022).

Why we inspected

The inspection was prompted in part by notification of two incidents following which a person using the service died and another person sustained a serious injury. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk of choking and environmental risks. This inspection examined those risks.

You can see what action we have asked the provider to take at the end of this full report. Please see the safe, effective, caring, responsive and well-led sections of this full report.

Enforcement and Recommendations

We have identified breaches in relation to person centred care, dignity and respect, consent to care and treatment, premises and equipment, safe care and treatment, nutrition and hydration, staffing and good governance.

Please see the action we have told the provider to take at the end of this report.

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 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. 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.

The overall rating for this service is ‘Inadequate’ and the service is therefore 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.