Ashley Court Care Home

Updated 1 October 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 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 one inspector, a pharmacist specialist and an Expert by Experience. 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 Court Care Home 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. Ashley Court Care Home is a care home without] nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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.

At the time of our inspection there was a registered manager in post.

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 sought feedback from Healthwatch Northampton. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England.

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 eight people using the service and two relatives, we sought their views about their experience of the care provided. We spoke with five care staff, the office administrator, laundry assistant, activity person, the registered manager and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

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 reviewed nine people’s medicines records, the medicines storage systems and observed a medicines administration round. We reviewed the care records for two people using the service and the recruitment records for two newly appointed staff. The provider’s policies and procedures and management quality assurance records were also reviewed.

Updated 1 October 2022

Ashley Court Care Home is a residential care home providing personal and nursing care for up to 38 people. The service provides support to older people, including people living with dementia. At the time of our inspection there were 33 people using the service.

The care home accommodates people across two floors, and on each floor, there is a lounge and dining area.

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

At the last inspection we identified missing information in two new staff members files such as references, recent photo and previous work history; the provider stated they would put support in place to ensure compliance. However, at this inspection we also found missing information in the two recruitment files viewed, such as, gaps in education and work history that had not been explored during the recruitment and selection process. After the inspection site visit the registered manager provided us with the missing information and told us they had completed a full audit on all staff files.

Reports carried out on behalf of the provider in February 2022 had identified essential repairs were needed to upgrade the fire alarm system. Following the inspection, the provider confirmed in writing that works to upgrade the fire alarm system had been completed on 29 August 2022.

Systems were in place to ensure medicines were ordered and disposed of safely and securely. However, good practice was not always followed when storing medicines. The procedures and record keeping for administering external medicines such as topical creams were unclear. The registered manager took immediate action during and after the inspection visit to rectify the areas identified.

Potential risks to people’s care and safety were assessed and kept under review to promote their safety. For example, equipment such as floor sensor (alert) mats were used for people at increased risk of falls. Pressure relieving equipment was used for people with frailty and poor mobility to reduce the risks of skin damage.

People using the service and relatives confirmed there were enough staff available to meet the needs of people using the service.

People were protected from the risk of abuse and told us they felt safe. There was a positive inclusive culture in the home. Care was person centred and people's individual characteristics were considered and planned into care.

People and their relatives spoke highly of the staff and management team and felt included and well supported.

The registered manager and management team were open and transparent. They focussed on improving the service. They worked in partnership with other health care professionals to achieve positive outcomes for people.

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.

Rating at last inspection and update

The last rating for this service was good (published 15 February 2021).

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Ashley Court Care Home on our website at www.cqc.org.uk.

Why we inspected

We received concerns in relation to the management of medicines and people’s care needs. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. We found no evidence during this inspection that people were at risk of harm from this concern.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified a breach in relation to staff recruitment.

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 to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.