Ashbury Lodge Residential Home

Updated 28 July 2022

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 team consisted of four 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

Ashbury Lodge Residential Home 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. Ashbury Lodge Residential Home 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 service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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.

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 sought feedback from the local authority and professionals who work with the service. 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.

During the inspection

During the inspection we spoke with six staff members including healthcare assistants, unit leaders, a chef and a domestic member of staff. We also spoke to eight people using the service and three relatives of people. We reviewed three care records, two medicine administration records (MARs) and observed a medication round. We also reviewed other records, including policies and procedures, relating to the safety and quality of the service.

After the inspection

We continued to seek clarification from the registered manager after the inspection visit to validate evidence found.

Updated 28 July 2022

About the service

Ashbury Lodge Residential Home accommodates up to 44 people in one adapted building. At the time of our inspection 34 people were residing at the home. Accommodation is arranged over two floors which are accessed via a lift or stairs. There is a small garden to the front of the building and a car park available to visitors.

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

People received a high level of care which met their needs. However, systems in place to monitor the quality and safety of people's care were inconsistent. Further improvement was needed to ensure governance was organised and evidenced decisions were made to follow other professionals’ advice. It also proved that changes in the care planning records system were necessary.

People felt safe and secure living in the home. People and their relatives were happy with the service and had good relationships with staff members. Risk associated with people's care had been identified and assessed. People received their medicines safely. There were enough staff deployed to meet people's needs. The environment was safe and there was equipment available to support staff in providing safe care and support. Health and safety checks of the environment and equipment were in place.

Where incidents or accidents occurred, there was evidence of analysis being completed to determine what measures could be put in place to improve people's safety. Relevant action was taken to reduce the risk of incidents while systems were put in place to keep people safe.

Cleaning and infection control procedures had been updated in line with COVID-19 guidance to help protect people, visitors and staff from the risk of infection. Government guidance about COVID-19 testing for people, staff and visitors was being followed.

People's needs were assessed prior to them using the service. There was ongoing training for all staff. Staff were supported with regular supervisions and were given the opportunity to attend regular meetings to ensure they could deliver care effectively. People were supported to eat a nutritionally balanced diet and to maintain their health.

People were supported to have maximum choice and control of their lives and staff provided them with care in the least restrictive way possible; the policies and systems in the service promoted this practice.

Staff treated people with kindness and respect, and spent time getting to know them and their specific needs and wishes. We observed positive interactions between staff and people who lived in the home. Staff were responsive to people's needs. People and their relatives knew how to raise concerns. There was a range of activities for people to enjoy.

The registered manager and staff had worked hard to address the shortfalls identified at the last inspection. The registered manager carried out a series of audits to check and monitor the quality of the service and ensure records were completed accurately. The registered manager provided clear leadership and considered the views of people, their relatives and staff in respect to the quality of care provided. The registered manager and staff used the feedback to make ongoing improvements to the 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 10 June 2021).

Why we inspected

The inspection was prompted in part due to concerns received from other healthcare professionals about people's safety and lack of communication with the service. A decision was made for us to inspect and examine those risks. We undertook a focused inspection to review the key questions of Safe, Effective, Responsive and Well-led only. For those key questions that were not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

We found no evidence during this inspection that people were at risk of harm from this concern. Please see the Safe, Effective, Responsive and Well-led sections of this full report.

The overall rating for the service has changed from requires improvement to good based on the findings of 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 continue to monitor information we receive about the service, which will help inform when we next inspect.