Archived: Ashbourne Lodge

Updated 1 April 2016

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 registered provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on the 16 February 2016 and was unannounced.

The inspection team consisted of two adult social care inspectors and three specialist professional advisors. (SPA). A SPA is a person who has a specialism in a certain area such as nursing or working with people living with a dementia.

Before our inspection, we reviewed the information we held about the home. We looked at statutory notifications that had been submitted by the home. Statutory notifications include information about important events which the provider is required to send us by law. This information was reviewed and used to assist us with our inspection.

The provider was not asked to complete a provider information return [PIR]. This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make.

During the visit we spoke with six people who used the service, two visitors, five staff members, the manager, the area manager, the deputy manager, the administrator, the head cook, the assistant cook and the handyman. We also carried out observations and looked at records, these included eight people’s care records, four staff files, audits and other relevant information such as policies and procedures.

Updated 1 April 2016

We carried out this inspection on the 16 February 2016. The inspection was unannounced which meant the staff and registered provider did not know we would be visiting

Ashbourne Lodge is a purpose build care home built across two floors. The lower floor Ash unit accommodates up to 23 people with residential care needs. At the time of our inspection there were 14 people living on the Ash unit. The upper floor is split into two units, the Cedar and the Oak. The Cedar unit offers accommodation for up to 15 people with residential care needs, at the time of inspection there were ten people living on the Cedar unit. The Oak unit is a dedicated dementia care unit designed for older people living with a dementia and can accommodate up to 17 people, at the time of our inspection there were eight people living on the Oak unit. Each unit has its own kitchenette area, where people who use the service, their visitors and relatives can make use of the tea and coffee making facilities. Each bedroom offers en-suite facilities and each unit also provides additional bathing and showering facilities. There is also an onsite laundry facility with dedicated laundry staff. The home itself is positioned in a residential area and offers designated parking to visitors and people who use the service. The total amount of people living at Ashbourne Lodge at the time of inspection was 32 people.

The service had a manager in place that was not registered with the Care Quality Commission. 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.

Risks to people arising from their health and support needs or the premises were not always assessed, and plans were not always in place to minimise them. A number of checks were carried out to monitor the safety of the premises. Personal Emergency Evacuation Plans (PEEPs) did not contain the required detail of information.

Neither the manager nor staff fully understood the requirements of the MCA and had a limited understanding of when they would need to consider if someone had the capacity to make decisions.

Due to sickness there were not sufficient numbers of staff to provide the support needed, call bells were ring constantly throughout the day. People in their own rooms were left for long periods of time. Staff did not receive regular supervisions and appraisals to monitor their performance.

Training for staff was not up to date and the training matrix was difficult to follow.

The registered provider did not always follow safe processes to help ensure staff were suitable to work with people living in the service.

People’s care records were person centred. Person centred planning (PCP) provides a way of helping a person plan all aspects of their life and support, focusing on what’s important to the person. The care plans were found to be very confusing, difficult to work through with a lot of duplicated information.

The registered provider had developed a quality assurance system and gathered information about the quality of their service from a variety of sources. However action plans were not always robust

Medicines were not always managed in a safe way. There were some concerns around the application of topical medicines.

We were told by people who used the service and staff that meetings had previously not occurred on a regular basis but since the new provider had taken over they were taking action to ensure regular meetings occurred.

The activity coordinator was on annual leave, we saw no evidence of activities taking place.

Staff understood safeguarding issues and felt confident to raise any concerns they had.

We observed staff to be caring to people. People’s privacy was respected and people said they felt safe and cared for.

People were supported to access healthcare professionals and services.

Accidents and incidents were monitored each month to see if any trends were identified. At the time of our inspection the accidents and incidents were too few to identify any trends.

We saw that the service was clean and tidy however there were some issues. For example, wheelchairs needed cleaning and there was malodour in some bedrooms. There was plenty of personal protection equipment [PPE] available.

We observed a lunchtime meal. People were provided with choice and enjoyed the food on offer. Some work was needed to improve the dining experience for people living with a dementia and people choosing to eat in their own rooms.

Staff felt positive about the change of ownership of the home.

The service had a system in place for the management of complaints.

We saw safety checks and certificates that were all within the last twelve months for items that had been serviced and checked such as fire equipment and electrical safety.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the registered provider to take at the back of the full version of the report.