Astley Hall

Astley Hall is a residential and nursing home providing personal and nursing care to up to 83 people. At the time of our inspection there were 55 people using the service.

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

People told us they felt safe and staff knew how to keep people safe and protect them from harm. People had individual risk's assessed with strategies in place to mitigate these risks.

Improvements had been made with the oversight of the service. Quality assurance systems need to be sustained and embedded to ensure they are consistent and reliable in identifying the shortfalls we found in record keeping.

People could be assured they received their medicines safely by trained and competent staff. Staff were recruited safely and there were enough staff to support people.

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.

Staff felt supported and spoke positively about the registered manager.

People, relatives and staff had the opportunity to provide feedback on the care provided and people spoke positively of the care they received.

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 April 2021); 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.

Why we inspected

The inspection was prompted in part due to concerns received about the management of medicines and staffing. 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 changed from requires improvement to good based on the findings of 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.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Astley Hall 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.

Astley Hall is a residential care home registered to provide personal and nursing care for up to 83 people. At the time of the inspection the service was supporting 6 people.

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

Records management required improvement. We found gaps in the recording of care tasks including repositioning checks, skin integrity checks and weight monitoring for people who required these tasks to be completed for health concerns.

Risks to people did not consistently have the strategies to mitigate these risks recorded. Records of injuries were at times inconsistent and investigation into how the injury had occurred was not always documented.

Systems in place to ensure safe management and administration of medicines were not always effective. Not all prescribed medicines had a medicine administration record and we found gaps in the recording of the administration of medicines.

Systems and processes to ensure oversight of the service and care given were not robust enough to identify the issues we found during the inspection. However, the manager and staff were open and transparent during the inspection. The manager sent through an action plan after the inspection to evidence the actions they were putting into place to rectify the concerns found.

The environment was clean and pleasant. However, the provider was still in the process of ensuring all signage was in place.

People and relatives were involved in their care planning and care plans were updated as required. Relatives were kept informed of people’s needs and any changes that occurred. People were supported to engage in activities and keep in contact with any significant people in their lives.

People were supported by trained staff who knew them well and who had been safety recruited. Care plans were person centred and supported the staff to know people’s diverse needs.

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.

The manager understood their responsibilities regarding the accessible information standard, duty of candour and submitting notifications and safeguarding concerns to the relevant agencies.

Staff felt supported by the management team and were able to raise any concerns or suggestion. Staff understood safeguarding and how to recognise signs of abuse.

People, relatives and staff knew how to complain, we found complaint had been responded to appropriately.

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

Rating at last inspection

This service was registered with us on 16 September 2020 and this is the first inspection.

Why we inspected

The inspection was prompted due to concerns received about infection control and record keeping. A decision was made for us to inspect and examine those risks.

We have found evidence that the provider needs to make improvements. Please see the safe 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.

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.

We have identified breaches in relation to assessing risks, medicine management and oversight of the service at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.