Ash Hall Nursing Home

Updated 11 May 2022

Inspection team

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.

Inspection team

The inspection was carried out by two inspectors on the first day of inspection and two inspectors on the second day. Additional relative feedback was gained by an assistant inspector 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

Ash Hall Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and we looked at both during this inspection.

The service had a manager registered with the Care Quality Commission. Registered managers and providers have legal responsibilities for how they run the service and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information received since the last inspection, including from the local authority and from Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. 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 inspected on 14 February 2022 and 16 February 2022. We spoke with three people who used the service, and one relative. We spoke with seven staff including care staff, senior care staff, nurses, the deputy manager, 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 looked at three people’s care records and multiple medicine records. We looked at how medicines were stored, administered and recorded. We looked at four staff files in relation to recruitment. A variety of records relating to the management of the service, including building safety records, audits and accident and incident records were also reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training records and other quality assurance records electronically. We held a virtual meeting with the registered manager and deputy manager to ask further questions and discuss our findings.

We spoke to 12 relatives on the telephone on 17 February 2022 and 18 February 2022 to gain their views.

Updated 11 May 2022

About the service

Ash Hall Nursing Home is a care home providing personal and nursing care to 49 people over 65 years some of whom may be living with dementia, physical disabilities, sensory impairments, or mental health at the time of the inspection. The service can support up to 60 people in one adapted building.

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

Risks to people were not always managed effectively to protect them from potential harm. Not all windows had compliant restrictors fitted and radiators were not always covered or not safely monitored in accordance with Health and Safety Executive requirements.

Some lessons had been learnt and improvements made since the last inspection. New systems and processes had been implemented to promote people’s safety, but some building safety concerns had not been found by the provider before our inspection. People, relatives and staff were positive about the management and felt able to approach the management team should they have any concerns.

There were enough staff to support people safely when we inspected, and recruitment is on-going to increase staffing levels, however staff were not always safely recruited.

People’s medicines were safely managed by staff. Staff followed infection control procedures.

People were included and empowered. People told us they were happy and they were involved in their own care. Relatives told us they were involved in care planning and reviews.

The service worked in partnership with other agencies to support people’s physical and mental health needs.

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 24 September 2019). The service remains rated requires improvement. This service has been rated requires improvement for the last three consecutive inspections.

Why we inspected

We received concerns in relation to staffing levels and infection prevention and control. 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 has not changed following this inspection.

We found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe and well-led sections of this full report. The provider told us they have installed compliant window restrictors where possible and risk assessed windows where not possible as well as monitoring radiator temperatures daily as the heat would be affected if they covered them. We will assess the effectiveness of these measures in the next inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Ash Hall Nursing 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 found breaches in relation to Regulation 17 (Good governance) at this inspection. We found a lack of compliant window restrictors to protect people from falls from height and insufficient measures in place to protect people from potential scalding and burns from uncovered radiators. This was not identified by the registered manager and therefore risks were not mitigated for people.

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.