Alsley Lodge

Updated 11 July 2020

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Act, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

Inspection team

The inspection team consisted of two inspectors and an expert by experience. An expert by experience is someone who has experience of the type of service being inspected.

Service and service type

Alsley Lodge is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with the Care Quality Commission. This means they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. The registered manager was on duty and she assisted us throughout the inspection process in a helpful manner.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

Prior to our inspection we checked all the information we held about the service. This included any notifications the service is required to send to us by law, any allegations of abuse or feedback about the service. We used all this information to plan our inspection.

The provider sent us a provider information return. A provider information return is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make.

During the inspection

To understand the experiences of those who used the service we spoke with eight people who lived at the home and observed interactions between staff and people. We also spoke with five relatives and six members of staff, including the registered manager. We looked at several records. These included three care files, medication administration records, two staff files, training records and associated documentation relating to the operation and management of the service.

After the inspection

We received a response and some clarification from the registered manager following our verbal and written feedback at the end of the inspection.

Updated 11 July 2020

About the service

Alsley Lodge is a residential care home registered to provide accommodation and personal care for up to 33 people. At the time of the inspection 31 people were living in the service.

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

We found the provider had not implemented systems to ensure risks to people’s health and safety were adequately promoted and the management of medicines could have been better. We have made a recommendation about staff competencies in relation to the management of medicines.

In general recruitment practices adopted by the home were satisfactory. However, the employment process for one member of staff could have been better. Therefore, we have made a recommendation about thorough employment checks being conducted for all new staff before they are appointed.

The approach of staff towards people was not always consistent and people were not always involved in the decision-making process. People were not always supported to have maximum control of their lives. Some daily routines did not support people’s choices and the policies of the home and these were not always followed in day to day practice. For example, some practices did not support people to have maximum choice of when they got up or when they had a bath or shower.

The governance of the service was not effective, as issues identified by the inspection team had not been recognised by the internal auditing systems and therefore the assessing and monitoring of the service was not robust.

Care plans varied in quality. Some needed to provide the staff team with clearer guidance about people’s current needs and how these needs were to be best met. However, others were well written and provided more detailed information.

The management of medicines could have been better. We made a recommendation about this.

Enough staff were on duty to meet the assessed needs of people who lived at the home. People looked relaxed in the company of staff and relatives confirmed they felt people were safe living at Alsley Lodge. A good range of training had been provided for the staff team. New employees were guided through an in-depth induction programme and processes were in place to ensure staff were supervised regularly. Community health and social care professionals had been involved in the care and support of people who lived at the home.

A range of activities were provided, which included visiting musicians and outings during the warmer weather. Some person-centred activities were also evident, such as visits to places of interest, based on individual preferences. There was confirmation of community engagement taking place.

We received positive feedback about the manager of the home and the staff team from people we spoke with and their relatives.

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

Rating at last inspection: The service was rated overall good at the last inspection (Published on 10 May 2017). However, the area of well-led was rated as requires improvement. We did not find any breaches of regulations and did not make any recommendations at that time. This was because the provider assured us they would implement a more robust auditing system and would display the CQC rating from the previous inspection more clearly within the home. At this inspection we found the CQC rating from the last inspection to be prominently displayed within the home. However, improvements to the auditing system were not evident.

Why we inspected: This was a scheduled inspection based on the previous ratings.

Enforcement: We have identified breaches in relation to safety, person centred care and good governance. You can see what action we have asked the provider to take at the end of this full report.

Follow up: The service will be re-inspected as per our inspection programme. We will continue to monitor any information we receive about the service. The inspection may be brought forward if any risks are identified.