Archived: Ashley Lodge Care Home

Updated 30 April 2022

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. 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 team consisted of two inspectors, one with specific knowledge of medicines. An Expert by Experience contacted relatives by telephone to obtain their feedback. 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

Ashley Lodge is a ‘care home’. People in care homes receive accommodation, nursing and personal care as a single package under one contractual agreement dependent on their registration with us. Ashley Lodge is a care home with nursing care. 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 that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We used the information the provider sent us in the provider information return (PIR). 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 reviewed other information we held about Ashley Lodge received since the last inspection including notifications of significant events that happened within the service. We used all this information to plan our inspection.

During the inspection

We spoke with one relative in person and five people who used the service. We spoke with eight staff members including a registered nurse, the registered manager, the maintenance person and care staff.

We reviewed records including 17 medicines records, and 12 care records. We looked at six staff recruitment and supervision records and a variety of records relating to management of the service including health and safety documents, service reports, audits and improvement plans.

After the inspection

We requested feedback from 15 staff members by email and received 10 responses. We contacted relatives by phone and received feedback from 10 of them.

Updated 30 April 2022

About the service

Ashley Lodge Care Home is a residential care home providing personal and nursing care to up to 77 people. The service provides support to people who have physical disabilities, require nursing care or who are living with dementia. At the time of our inspection there were 48 people using the service.

Ashley Lodge accommodates up to 55 people in the main premises consisting of a converted house and large extension. An additional annexe could house an additional 22 people however this has been decommissioned for several years and there are no current plans to reopen these beds. These premises house staff who are working under a sponsorship scheme.

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

Medicines were managed safely for people. However, we recommend some improvements should be made to medicine related records.

Risks were considered and safely managed, and people were supported by staff trained in safeguarding and who would whistle-blow if they had concerns about colleagues.

There were usually sufficient staff deployed to meet needs and the registered manager assured us they would only increase numbers of people using the service as they increased staffing levels.

The premises were very clean to minimise the potential spread of infection and people, staff and visitors to the service were tested for COVID-19 in line with government guidance.

People were supported by staff trained in a wide range of subjects and who received regular support from senior staff through meetings and supervisions.

Nutritional care plans based on advice from healthcare professionals ensured people had the correct diet for them and we received positive feedback about meals.

Referrals were made to appropriate health and care professionals and relatives were kept informed about their family member.

The premises were purpose built and met the needs of people and there was an ongoing maintenance and refurbishment programme.

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.

There was an open culture in the service and staff were supported to speak up and share concerns should they have any. The management team were also open and contributed fully to our inspection. We received mixed feedback from relatives about the management team however most feedback praised them.

There was an ongoing improvement plan that was reviewed constantly and a programme of audits ensured progress was being made.

The provider ensured that people and their relatives remained involved with the service through use of virtual meetings and quality assurance questionnaires that were sent out at intervals.

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 (published18 March 2019). 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

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective and Well-led which contain those requirements.

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. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Ashley Lodge Care Home 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.