Aylestone Grange

Updated 8 June 2023

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 completed by one inspector.

Service and service type

Aylestone Grange 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. Aylestone Grange 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 sought feedback from the local authority team. 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 reviewed information we had received about the service, including statutory notifications sent by the provider. Statutory notifications are events that the provider is legally required to tell us about. We used all this information to plan our inspection.

During the inspection

We spoke to 4 staff and the registered manager. We observed the care provided to people.

We reviewed a range of records. This included 2 people’s care records and medication records. We looked at 2 staff files in relation to the safety of recruitment. A variety of records relating to the management of the service, including policies, training records and procedures were also reviewed.

Updated 8 June 2023

About the service

Aylestone Grange is a small residential care home. Staff are registered to provide support to people with a mental health condition and/or substance misuse needs. At the time of the inspection, 9 people were living at the service but only 2 people received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do we also consider any wider social care provided.

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

Staff did not always have clear written guidance on how to support people. However, staff had received training and had good knowledge of people’s needs. Therefore, this poor documentation had not caused unsafe care.

Medicines were mostly managed safely. Some improvements were needed to the documentation of ‘as needed’ medicines. However, because staff had good knowledge of people’s medicine needs this did not impact people’s safety.

There were not always mental capacity assessments recorded for people. This lack of recording meant we were not assured that people’s ability to make decisions had been assessed. However, staff had good knowledge on how to support people to make decisions.

There were enough staff and these staff were safely recruited. Incidents were managed safely. People were kept safe from abuse. Professionals visited the service and staff had good knowledge of how these professionals supported people.

The care home was not always well managed. This is because concerns related to care planning, ‘as needed’ medicines and mental capacity assessments had not always been resolved in a timely way. Staff fed-back positively about the registered manager and advised they supported them well.

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 11 November 2020)

Why we inspected

The inspection was prompted due to an incident that had resulted in a serious injury to the person. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. We found no evidence during this inspection that people were at risk of harm from this specific concern.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed to requires improvement, based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Aylestone Care Home on our website at www.cqc.org.uk.

Enforcement

We have identified a breach of regulation. This is in relation to the governance and oversight of the service. 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.