31 March 2022
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 included checking the provider was meeting COVID-19 vaccination requirements. 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.
The inspection was carried out by two inspectors and an Expert 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
Ashgrove 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. Ashgrove 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.
There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.
Notice of inspection
This inspection was unannounced.
What we did before the 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 (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 used all this information to plan our inspection.
During the inspection
We spoke with six people who used the service and three relatives about their experience of the care provided. We spoke with 12 members of staff including the area director, registered manager, nurses, care assistants, the activity coordinator, laundry person and the chef.
We reviewed a range of records. This included six people’s care records and multiple medication records. We looked at four staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records.
31 March 2022
About the service
Ashgrove Care Home provides personal and nursing care to people aged 65 and over. The service can support up to 50 people. Care is provided over two floors. The service is managed by HC-One Limited, a national provider of nursing and care homes. There were 46 people using the service at the time of our inspection.
People’s experience of using this service and what we found
Risk assessments contained guidelines and plans for staff on how to minimise risks for people using the service. However, we observed that staff did not always follow these.
Although people told us they felt safe when receiving care, we found that some practices were putting people at risk of avoidable harm. Staff did not always have the right information about people and this meant people’s needs were not always met safely.
We found evidence that clinical checks were sometimes recorded in advance so we could not be sure people were monitored appropriately and this put them at further risk of harm.
People’s needs were recorded in their care plans but these did not always contain accurate information or were not always updated following healthcare professionals’ advice. This meant there was a risk that people’s needs might not be always met.
The provider had processes in place for the recording and investigation of complaints and incidents and accidents.
People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not always support this practice.
The management team did not always communicate well where there were concerns. This contributed to delays investigating concerns raised. The provider had monitoring systems in place, but these had not been effective as they had failed to identify the issues we found during our inspection.
There were enough staff to support people and meet their needs. Staff were recruited appropriately, and all checks were in place. Staff received an induction, training and supervision and felt supported in their roles. However they said supervision was mainly carried out as a result of a concern raised rather than a regular occurrence.
The provider sought feedback from people. People and staff told us they could raise any concerns they had with the registered manager and felt they would be listened to. We received positive feedback from people who used the service. People said staff were caring and treated them with dignity and respect.
The registered manager and senior staff were responsive to and worked in partnership with other agencies to investigate concerns and make improvements.
Medicines were managed safely to ensure people received their medicines as prescribed and in line with national guidance.
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 8 June 2021).
Why we inspected
We received concerns in relation to people’s care needs not being met. As a result, we undertook a focused inspection to review the key questions of safe, responsive 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. This included checking the provider was meeting COVID-19 vaccination 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 good to requires improvement based on the findings of this inspection.
We have found evidence that the provider needs to make improvements. Please see the safe, responsive and well-led sections of this full report.
You can see what action we have asked the provider to take at the end of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Ashgrove Care Home on our website at www.cqc.org.uk.
Enforcement and Recommendations
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 safe care and treatment, person-centred care, receiving and acting on complaints and good governance at this inspection.
Please see the action we have told the provider to take at the end of this report.
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
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.