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Ashleigh House Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 22 June 2018

We inspected this service on 26 March 2018 and 12 April 2018. The inspection was unannounced.

Ashleigh house is a care home. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The care home accommodates up to 24 older people in one adapted building. Accommodation is based on the ground floor as well as the first and second floors of the building.

There were 16 people living in the home on the first day of our visit and 14 people on the second day. Most of these were older people and some were living with dementia.

At our last inspection in November and December 2017 we rated the service as ‘requires improvement’ overall. We found a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 because risks related to people’s health and safety were not safely managed. There was a breach of Regulation 18 because the provider had not reported notifiable incidents to us without delay. There was also a breach of Regulation 17 because the provider did not ensure people were protected from risks to their health and safety, and systems and processes were not effective in monitoring and driving improvement. The key questions of Safe, Responsive and Well Led were all rated ‘Requires Improvement’. The provider sent us an action plan, setting out the actions they planned to take to improve the quality of the service. At this inspection, we checked whether the actions they had taken were effective. We found the provider was no longer in breach of two of the three regulations previously identified. Due to further improvement needed, there was a continued breach of Regulation 17 and the rating remained requires improvement.

Action was needed to improve person centred care, ensure care decisions related to restrictions in care were in people’s best interests, and to ensure audit processes were consistently effective.

There was a registered manager in post as the manager who had been in post at our previous inspection had registered with us on 4 May 2017. A registered manager is a person who has registered with the Care Quality Commission 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 atmosphere in the home was relaxed and people spoke positively of the staff who supported them. Staff were caring in their approach but some staff were more interactive with people than others. People said they felt their privacy and dignity was maintained. However, CCTV had been in use at the home which most people and visitors were unaware of which can compromise people’s privacy and dignity.

People did not always experience person centred care and information in care plans was limited in regards to people’s backgrounds and interests. This meant staff had limited information to assist them in providing care centred on the person’s individual needs. Some people told us they wanted more opportunities to go out of the home and to participate in activities that were of interest to them. People were able to maintain relationships and friendships with those important to them and visitors confirmed they were welcomed into the home. Where people had identified healthcare needs, some records did not support staff to help ensure they always addressed them effectively.

The provider carried out a series of recruitment checks to make sure staff were suitable to work at the home before they supported people at the home. People told us they felt safe living at Ashleigh House and said they could access staff when they needed and staff were caring and approachable. We saw enough staff were available to support people’s care

Inspection areas


Requires improvement

Updated 22 June 2018

The service was not consistently safe.

There were enough staff to meet people’s basic care needs and senior staff were available in the absence of the registered manager. Staff knew to report any concerns related to people’s wellbeing to their manager. Some practices associated with medicine management needed to be improved. Records related to risk management were not clear enough to demonstrate people’s care needs were effectively and safely managed. Recruitment processes ensured staff were safe to work with people.


Requires improvement

Updated 22 June 2018

The service was not consistently effective.

Staff completed training on an ongoing basis to help ensure they had the right skills and knowledge to support people effectively. The registered manager and staff had some understanding of the Mental Capacity Act (2005) but restrictions had been applied to some people’s care without full consideration if these were in the person’s best interest. People were supported to attend appointments with external healthcare professionals to maintain their health and wellbeing. People enjoyed the meals and a choice was provided.


Requires improvement

Updated 22 June 2018

The service was not consistently caring.

People spoke positively of the staff but had varying experiences of involvement in their care to support their wellbeing. Staff offered reassurance when supporting people and did not rush them. People felt staff respected their privacy and dignity but CCTV had been in use which most people had not been aware of. We saw staff aimed to support people’s independence.


Requires improvement

Updated 22 June 2018

The service was not consistently responsive.

People had some involvement in decisions related to planning their care. People were given opportunities to participate in some social activities within the home and work was ongoing to develop these further. Care plans were regularly reviewed and contained some person centred information to support staff in supporting people’s needs and preferences. People knew how to raise concerns if they needed to and those received had been considered and responded to.


Requires improvement

Updated 22 June 2018

The service was not consistently well led.

People had opportunities to share their views of the home and overall these were positive. The provider monitored the quality of the care and services through meetings, satisfaction surveys and regular audits of the service. There remained areas for improvement which needed to be acted upon and processes and systems continued to be developed to monitor these so they were fully effective. Most statutory notifications regarding incidents and accidents in the home had been reported to us as required.