This inspection was unannounced and took place on 7 and 11 September 2015. At our last inspection in August 2013 no concerns were identified.
Ashcombe Court provides accommodations for up to seven people who have a learning disability or mental health needs who require support and personal care.
At the time of the inspection there were seven people living at the home. Ashcombe court has seven bedrooms, two on the ground floor and five on the first floor all have en-suites. There is a communal dining room, lounge, kitchen for people to make their own drinks in, medication room, office, laundry room, outside front garden and rear patio and seating area. The first floor also has a staff sleeping room and bathroom.
There was a registered manager in post. 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. The registered manager was present on both days of the inspection.
People could be at risk due to incomplete and out of date records. People felt safe and were supported by staff who knew about abuse and who had attended training. There was a safe system in place for the recruitment of new staff. People had their medication administered safely by staff who were trained and competent in their role. The home had safety checks completed to ensure the building and appliances were safe.
People’s rights were not fully protected because they were not supported to access training to enable them to make their own decisions. Applications were not being made when people were having restrictions on their daily routines. Menus were based on people’s know likes and meals were flexible to when people wanted them. People who at risk of poor nutrition did not have accurate records completed that confirmed meals and the daily totals.
Staffing levels at the home were good. Staff knew people’s individual communication needs and used body language and gestures for people who required additional support with their communication. Staff felt happy and well supported by the management team, they were happy with the training and the improvements made to the staff induction. People were supported by enough staff and this was provided to ensure people had their support and one to one activities. People had their medication administered by staff who were trained and competent.
People did not always have their needs identified when they changed. Although people were supported by staff who were kind and caring. Staff were able to demonstrate how they gave people dignity and respect whilst supporting them. People received support from people who knew them well and were supported to maintain contact with friends and family. Care plans were person centred and people were able to develop weekly planners that included activities important to them. Reviews were undertaken and involved people and their relatives when required.
Audits in place were failing to monitor the quality of the service relating to accurate records and lack of mental capacity assessments. Not all notifications were being made when required to The Care Quality Commission. There was a complaints and easy read policy in place. Annual surveys were sent to people, relatives and professionals about the quality of the service and all people responded positively to the care they received.
We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
You can see what action we told the provider to take at the back of the full version of the report.