Background to this inspection
Updated
17 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.
Inspection team
The inspection was carried out by 1 inspector.
Service and service type
Ashville House 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. Ashville House 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 a registered manager in post.
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. 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 used all this information to plan our inspection.
During the inspection
We spoke with the registered manager, 2 staff, 2 people who lived at the home and 1 relative. We observed interactions of care. We viewed 3 care records including people’s medicines records. We viewed 4 staff records in relation to recruitment and their training. We also reviewed a variety of records relating to the management of the home, which included policies and procedures.
Updated
17 February 2024
About the service
Ashville House is a residential care home which provides support for up to 3 people needing personal care and mental health support. The home is an adapted terraced house in a residential area. At the time of our inspection there were 3 people using the service.
People’s experience of using this service and what we found
During this inspection recruitment records were not accurate or easily accessible. We found disclosure and barring service checks were not always up to date and references were missing in one recruitment file.
We were not assured people were being supported to receive medicines on an as required basis appropriately, as medicine administration records were not accurate and there was no protocol to explain when people should receive them.
Staff training was not up to date, we were not assured the registered manager had effective oversight to manage staff training to ensure they completed their learning before expiry. Staff were not receiving regular supervision support. This meant we had concerns staff did not have up to date knowledge to support people at the home.
Quality assurance was not effective in the home audits, were not being completed for medicines and recruitment checklist audits were not accurate.
Equality and diversity was not always understood by staff where people were at risk of being discriminated against. We have made a recommendation about equality and diversity.
People were supported to have enough to eat and drink but choices were not always respected.
We have made a recommendation about nutrition and hydration.
People, relatives and staff views were not always gathered within the home to drive improvement.
We have made a recommendation about engagement with people, relatives, staff and health professionals.
There were enough staff to support people at the home and people told us they felt safe living there. People’s other prescribed medicines was administered safely.
People’s risk were assessed and measures put in place to reduce the risk of harm. Staff knew people’s risks and how to keep them safe. Staff knew their safeguarding responsibilities despite not receiving up to date training in the area. The home was clean and infection was managed well within the home.
Consent to care and treatment was requested before care began and staff asked people for their permission before providing personal care support.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
The home worked well with health professionals to ensure they received prompt care and support and the registered manger found ways to support a comfortable experience for people when medical procedures were being carried out.
The home was warmly decorated and people could personalise their rooms as they wished. The home was accessible for people living there with access to a small garden.
People told us staff were kind and caring. Staff were patient with people and treated people with respect. Privacy and dignity was respected within the home and staff encouraged people’s independence.
People’s care plans were personalised to reflect their preferences and people’s communication needs were met. People were able to enjoy different activities and supported to travel abroad. Systems were in place to respond to people’s complaints.
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 good (published 29 August 2018).
Why we inspected
This inspection was prompted by a review of the information we held about this service.
Enforcement and Recommendations
We have identified breaches in relation to the safe management of medicines, safe recruitment, staffing and good governance.
Please see the action we have told the provider to take at the end of this report.
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. We will continue to monitor information we receive about the service, which will help inform when we next inspect.