Ailwyn Hall

Updated 17 April 2021

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

As part of CQC’s response to the COVID-19 pandemic we are looking at the preparedness of care homes in relation to infection prevention and control. This was a targeted inspection looking at the infection control and prevention measures the provider has in place.

This inspection took place on 17 March and was announced.

Updated 17 April 2021

This inspection took place on 17 and 18 September 2018. The first day was unannounced.

Ailwyn Hall 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 both were looked at during this inspection.

Ailwyn Hall is registered to accommodate up to 39 people. Care is provided over two floors. There are communal areas that people can reside in along with space for dining on the ground floor. At the time of our inspection visit, 18 people were living in the home.

A registered manager worked in the home. A registered manager is a person who has registered with the Care Quality Commission 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.

At the last inspection of Ailwyn Hall in February 2018, we rated the home overall as Inadequate. This was because: risks to people’s safety had not been adequately managed; systems to protect people from the risk of abuse were not robust; consent had not been sought from people in line with the relevant legislation; some areas of the premises and equipment people used was unclean; staffing levels were not consistently adequate and staff had not received appropriate training to provide effective care; the governance processes in place were not robust at identifying issues or improving the quality of care provided to people and the provider had not ensured they had notified the Care Quality Commission (CQC) of notifiable events as is required by law. This resulted in six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the CQC registration regulations 2009.

Following that inspection visit, we took urgent action to protect people from the risk of harm. This was in the form of placing a condition on the provider’s registration. This condition prevented them from admitting people into the home and told them they must send us a weekly report detailing how they were managing specific risks to people’s safety. We also placed the home in special measures. Services that are in special measures are kept under review and inspected again within six months from the publication of the report. We expect services to make significant improvements within this timeframe.

The provider had complied with the additional condition we had placed on their registration and at this inspection we found that significant improvements had been made. The provider was no longer in breach of any regulations. The overall rating of the home has changed from Inadequate to Good. Due to this, the home has been taken out of special measures. However, although systems were in place to monitor the quality of care provided to people and any areas for improvement that had been identified had been acted upon, the provider has not consistently met and therefore maintained the required standard of care to ensure that people consistently receive a good level of care. This is why we have rated well-led as requiring further improvement.

Risks to people’s individual safety had been assessed and managed well. Staff had acted to mitigate the risk of people experiencing harm as much as possible.

Systems were in place to reduce the risk of people experiencing abuse. Where incidents or accidents had occurred, these had been thoroughly investigated to try to prevent them from re-occurring.

People received their medicines when they needed them and there were enough staff to keep people safe and to meet their needs. The home was visibly clean as was most of the equipment that people used.

The staff had received appropriate training and supervision to provide people with safe and effective care. The staff were kind, caring and compassionate towards people and treated them with dignity and respect.

People received enough to eat and drink to meet their needs and they were seen by healthcare professionals quickly if they needed to. This was to help them maintain their health.

People were treated as individuals and were involved in making decisions about their own care. Where people lacked capacity to make their own decisions, staff acted in line with the relevant legislation.

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

Staffing levels had been planned to enable staff to spend time with people and to engage them in activities and stimulation to enhance their wellbeing.

The registered manager had instilled an open culture within the home where people were treated as individuals and were valued. The staff were happy working in the home and demonstrated good teamwork and organisation.

The registered manager was keen to continually improve the quality of care people received and had many ideas they were exploring using best practice and guidance.