Ashurst Mews Care Home

Updated 28 September 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

This inspection was carried out by two inspectors.

Service and service type

Ashurst Mews Care 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. Ashurst Mews Care Home is a care home with 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 not a registered manager in post.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 03 August 2022 and ended on 09 August 2022. We visited the location on 03 August 2022.

What we did before the inspection

We used the information the provider sent us in the provider information return. 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.

What we did before 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. 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 used all this information to plan our inspection.

During the inspection

We spoke with six people who used the service and seven relatives about their experience of the care provided. We spoke with 14 members of staff including a regional support manager, an operations manager, a general manager, a deputy manager, a nurse, a maintenance staff member, a kitchen staff member, five permanent care staff and two agency care staff.

We reviewed a range of records, including four people’s care records, multiple medicines records and six staff files in relation to recruitment. We also looked at a variety of records relating to the management of the service, including quality assurance records.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We spoke with the estates manager and looked at care documentation, training data, quality assurance and maintenance records.

Updated 28 September 2022

About the service

Ashurst Mews Care Home is a residential care home providing nursing and personal care to up to 60 people. The service provides support to older people and people living with dementia. At the time of our inspection there were 53 people using the service.

Ashurst Mews accommodates people across three separate areas, each of which has separate adapted facilities. On the ground floor, support is provided to people with residential needs. On the second floor there are two separate areas, one providing support to people with dementia and the other support to people with nursing needs.

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

Systems to monitor the quality and safety of the service were in place to ensure people received safe and person-centred care. These required time to be embedded in the service to ensure they were sustained and improvements continued.

The systems and processes for identifying risks to people had improved. Further improvements were required to ensure effective management of risks to people’s skin integrity, people’s health needs and environmental risks.

Staffing levels and deployment had improved but further improvement was required to ensure people were consistently supported by sufficient numbers of staff who knew them well. People were supported by staff who were safely recruited and were supported within their roles.

People received their medicines as prescribed from trained staff.

People's needs were assessed, and care plans guided staff how to meet those needs. A system was in place to monitor people's health needs.

Staff felt supported within their roles and felt confident to discuss any concerns they may have with the management team.

Feedback was sought from people, relatives and staff to identify where improvements were needed. Staff, people and relatives were also offered regular meetings to share information and discuss any concerns they had.

People were protected against infections such as COVID-19. Staff followed government guidance on testing and wearing appropriate personal protective equipment (PPE). The home appeared clean. Cleaning schedules were in place to evidence when cleaning was completed.

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

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 requires improvement (published 09 March 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 improvements had been made and the provider was no longer in breach of regulations. The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

The inspection was prompted in part due to safeguarding concerns and concerns about the leadership and management of the service. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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.

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 remains 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 Ashurst Mews Care Home on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.