Ashgrove Care Home - London

Updated 14 April 2023

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 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 was carried out by 2 inspectors and 1 Expert by Experience on the first day of the inspection. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service. A medicines inspector visited the service on the second day.

Service and service type

Ashgrove care home - London is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Ashgrove care home - London is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection the registered manager had just resigned from their post and a temporary manager was in place.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. 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 used all this information to plan our inspection.

During the inspection

We spoke with 6 people who used the service and 1 relative about their experience of the care provided. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We spoke with 12 members of staff including the regional director, area director, manager, nurses, care assistants, the activity coordinator, laundry person and the chef.

We reviewed a range of records. This included 6 people’s care records and multiple medication records. We looked at 5 staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed. After the inspection, we continued to seek clarification from the provider to validate evidence found. We looked at the provider’s action plan, audits and checks, care records and meeting minutes.

Updated 14 April 2023

About the service

Ashgrove Care Home provides personal and nursing care to people aged 65 and over. The service can support up to 50 people. Care is provided over two floors. The service is managed by HC-One Limited, a national provider of nursing and care homes. There were 33 people using the service at the time of our inspection.

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

There were systems in place to protect people from the risk of infection and staff had received appropriate training in this. However, there were areas of the kitchen which were unclean and required deep cleaning although cleaning schedules indicated these tasks had been carried out.

Risks to people’s safety and wellbeing were overall appropriately assessed and mitigated, however, on the day of our inspection, two bathrooms containing tools, stored items and a wet floor had been left unattended and unlocked. This presented a risk to people who used the service.

People’s records were not always completed correctly, appropriately and in a person-centred way.

There were systems in place to monitor the quality of the service and these were mostly effective. Although the provider had made improvements, monitoring checks had failed to identify some of the issues we found during the inspection.

People’s healthcare and nutritional needs were met. People were supported to access healthcare professionals and to attend appointments as needed.

Medicines were managed safely and people who used the service received these as prescribed.

The provider sought feedback from people. People and staff were confident they could raise any concerns they had with the provider and felt they would be listened to. We received positive feedback from people who used the service. People said staff were caring and treated them with dignity and respect.

There were enough staff to support people and meet their needs. Staff were recruited appropriately, and all checks were in place. Staff received an induction, training and supervision and felt supported in their roles.

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 management team were responsive to and worked in partnership with other agencies to meet people’s needs.

Rating at last inspection (and update)

The last rating for this service was requires improvement (published 31 March 2022) and there were multiples breaches of regulations. We issued the provider Warning Notices for Regulations 12 and 17. 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. However, we found some areas which required further improvement.

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, Responsive 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 not changed. 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 Ashgrove Care Home - London on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to regulation 12 (safe care and treatment) and regulation 17 (good governance) at this inspection.

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

Follow up

We will request an action plan from 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 continue to monitor information we receive about the service, which will help inform when we next inspect.