Ashley Care

Updated 30 November 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.

Inspection team

The inspection team consisted of two inspectors and two Experts 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

This service is a domiciliary care agency. It provides personal care to people living in their own houses, flats and specialist housing.

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

We gave the service 48 hours’ notice of the inspection. Inspection activity started on 27 September 2022 and ended on 17 October 2022. Two inspectors visited the office location on 27 and 28 September 2022.

What we did before the inspection

The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We asked the registered manager to provide us with their most recent call visits times to people. We reviewed all the information we held about the service. We took this into account when we inspected the service. We used all information to plan our inspection.

During the inspection

We spoke with the new chief operating officer the registered manager, and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We reviewed a range of records. This included six people’s care records, associated risk assessments and Medication Administration Records [MAR]. We looked at three staff files in relation to recruitment, training, supervisions and spot checks. We looked at a sample of the service’s quality assurance systems, and complaints management records. The Experts by Experience spoke with 23 people who used the service or their relative about their experience of the care provided.

Following the inspection to the domiciliary care office, we continued to seek clarification from the registered manager to validate evidence found. We spoke to a further six members of staff by telephone.

Updated 30 November 2022

About the service

Ashley Care is a domiciliary care service providing personal care and support to people in their own homes. Not everyone who used the service received personal care. At the time of our inspection, the domiciliary care service was providing support to 107 people, 80 of those were receiving support with 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

The provider’s governance arrangements did not provide assurance the service was well led, and regulatory requirements were not being met.

People told us they had not had any missed calls; however, they were often not informed if staff were running late, and this impacted on people receiving their calls at their scheduled times.

We have made a recommendation about the management of some medicines.

Staff had been safely recruited; however, we were not satisfied staffing levels and deployment of staff ensured all people’s care needs were met in a timely way.

Risks to people had been identified, assessed and reviewed.

People and their relatives told us they felt safe using the service. People were cared for by staff who knew how to keep them safe and protect them from avoidable harm.

The majority of staff felt confident their training provided them with the knowledge they needed to support people safely.

Staff had access to personal protective equipment (PPE) and there were effective infection prevention and control measures in place.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update: The last rating for this service was inadequate (published May 2022) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found significant improvements had been made with regard to regulation 18 [Staffing] and regulation 12 [Safe care and treatment]. However, the provider remained in breach of regulation 17 [Good governance].

This service has been in Special Measures since May 2022. During this inspection the provider demonstrated improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements. 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 from Inadequate to Requires Improvement. This is based on the findings at this inspection.

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

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to governance at this inspection.

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.