Archived: Ascot Lodge Nursing Home

Updated 11 March 2021

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

As part of CQC's response to the coronavirus pandemic we are looking at the preparedness of care homes in relation to infection prevention and control. This was a targeted inspection looking at the infection control and prevention measures the provider has in place.

This inspection took place on 24 February 2021 and was unannounced.

Updated 11 March 2021

This inspection took place on 14 and 16 May, 2018 and was unannounced.

Ascot Lodge is a small ‘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.

Ascot Lodge is registered to provide accommodation with nursing and/or personal care for up to 18 older people. At the time of the inspection there were 16 people living in the home. Accommodation includes a TV room and dining room, 12 single bedrooms and two double bedrooms which can all be found across four floors. The home had been adapted for people with limited mobility. There is an enclosed garden and patio at the rear of the building and a small car park at the front.

At the time of the inspection there was a registered manager in post. 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. During the inspection we found the registered manager to be open, transparent and receptive to the feedback provided.

At the last inspection which took place in September, 2017 we identified breaches of Regulations 10, 11, 12, 17 and18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Ascot Lodge was awarded an overall rating of ‘Requires Improvement’. Following the inspection we issued a warning notice regarding Regulation 17 and asked the registered provider to complete an action plan to tell us what changes they would make and by when. During this inspection, we looked to see if the registered provider had made the necessary improvements.

At the last inspection, we found that people who lived at Ascot Lodge did not always have their dignity and respect preserved. People's privacy was not always maintained and care was not always provided in a dignified way. During this inspection we found that people were treated with dignity and respect. People and relatives we spoke with expressed their satisfaction with the provision of care which was provided. We found that improvements had been made and the registered provider was no longer in breach of this regulation regarding ‘Dignity and respect’.

At the last inspection we identified that the registered provider was not complying with the principles of the Mental Capacity Act, (MCA) 2005. Consent was not gained in line with the MCA. People living in the home were not being appropriately assessed, assessments were not decision specific and 'best interest' processes were unclear. During this inspection we found that improvements had been made and the registered provider was no longer in breach of this regulation regarding ‘Need for consent’.

At the last inspection we found that the registered provider was in breach of regulation in relation to ‘Safe care and treatment’ This was because people were exposed to unnecessary environmental risks and the delivery of care and support was not always safely managed. We found the environment posed significant risks to people who were being supported, medication management systems were unsafe and accidents and incidents were not being sufficiently monitored. During this inspection we found that the registered provider was no longer in breach of this regulation in relation to ‘Safe care and treatment’.

At the last inspection, we found that staff were not receiving adequate supervision or annual appraisals. Staff expressed that they felt supported but were not receiving formal supervisions or appraisals to help develop them further in their roles. During this inspection we found staff received regular supervisions and annual appraisals were taking place. The registered provider was no longer in breach of this regulation regarding ‘Staffing’.

At the last inspection we found that local audit and governance systems were ineffective. The systems which were in place did not effectively monitor and assess the quality and standard of care people were receiving. During this inspection we looked at the governance systems, audits and checks which were in place and found that improvements had been made. Audits were routinely completed, the quality and standard of the care being provided was being assessed and improvement action plans were in place. Although the registered provider was no longer in breach of regulation in relation to ‘Good governance’ further improvements were required.

We have recommended that the registered provider reviews some of the systems further to improve the quality and standard of care being provided.

People and relatives told us that the service was safe. Staff were knowledgeable around the area of safeguarding and whistleblowing procedures; they knew how to report any concerns and who to report their concerns to.

We found that there was sufficient numbers of staff on duty to meet the needs of people in a timely way. We received positive feedback from people, relatives and staff about the staffing levels at the home. Staff were visible throughout the inspection and were responsive to people’s needs.

Accidents and incidents were routinely recorded and analysed. We found that all accidents/incidents were being recorded in care records, the necessary care plans and risk assessments were being updated and trends were being established in order to mitigate further risk.

We found the home to be clean, hygienic and odour free. Communal areas, toilets, bathrooms and bedrooms were well maintained. Staff had access to personnel protective equipment (PPE) such as gloves, aprons and hand gels.

We reviewed health and safety audit tools which were in place to monitor and assess the quality and standards of the home. There was a variety of different audits/checks being conducted which meant that people were living in a safe environment.

People’s nutrition and hydration support needs were safely managed. People were regularly assessed and measures were in place to monitor and mitigate risk. We found that appropriate referrals were being made to external healthcare professionals and the guidance which was provided incorporated within care plans.

Recruitment was safely managed. People who were employed had undergone the necessary recruitment checks. We found suitable Disclosure Barring System checks (DBS) in place and appropriate references had been sought prior to employment commencing.

Reasonable adaptations and adjustments had been made to the environment to support people who had limited mobility. People were appropriately supported and independence was encouraged.

People living at Ascot Lodge told us that staff were kind, caring and friendly. Interactions we observed between staff and people living in the home were warm, sincere and familiar. It was evident that staff were familiar with the people they were caring for.

Confidential information was stored securely. People’s personal information was appropriately protected and sensitive information was not unnecessarily being shared with others.

A person centred approach to care was evident; newly revised paperwork was being implemented to further improve person centred care people received. It was clear that staff were familiar with the people they were supporting and how the support needed to be provided.

A complaints policy and procedure was in place. People and relatives told us that they knew how to raise any concerns if they ever needed to.

The range and variety of activities had improved since the last inspection. People and relatives told us they enjoyed the activities available and were able to choose whether or not they wanted to join in. There was a schedule of different activities advertised around the home and people were encouraged to express what activities they wished to engage in.

Systems were in place to gather feedback regarding the provision of care being provided. People, staff and relatives were encouraged to share their views, opinions and thoughts around the standard and quality of care people received. These included staff and ‘resident and relative ‘questionnaires’, resident/relative and staff meetings, meal experience forms, dignity activity surveys.

Following the last inspection the registered provider submitted a number of different action plans to evidence how they were progressing with their improvements. During the inspection we identified that actions were being completed and the quality and standard of care being provided had improved.

The registered manager had notified the Care Quality Commission (CQC) of all events and incidents that occurred in the home in accordance with our statutory requirements and ratings from the last inspection were displayed within the home and on the registered provider’s website as required.