Ashgrove Residential Care Home

Updated 9 June 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 1 inspector 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

Ashgrove Residential 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. 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 there was a registered manager in post.

Notice of inspection

The inspection was unannounced.

What we did before the inspection

We reviewed the information we already held about the service. This included the last inspection report and notifications. A notification is information about important events, which the provider is required to tell us about by law. 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 of this information to plan our inspection.

During the inspection

We spoke with the provider, registered manager, deputy manager, 5 care staff, the chef and a maintenance staff member.

We carried out observations of people’s care and support and spoke with 5 people and 5 visiting relatives for their feedback on the home.

We reviewed documents and records that related to people’s care and the management of the service. We reviewed 5 care plans, which included risk assessments and 4 staff files, which include pre-employment checks. We looked at other documents such as those for medicine management and infection control. After the inspection, we continued to seek clarification from the provider to validate evidence found.

Updated 9 June 2023

About the service

Ashgrove Residential Home is a residential care home registered to provide accommodation and personal care to 26 older people. The service is a two-floor building. Each floor has separate adapted facilities. At the time of our inspection, the service provided personal care to 20 people.

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

At our previous comprehensive inspection of this service on 12 October 2021, we found robust quality assurance systems were not in place to identify shortfalls we found with risk assessments, infection control, need for consent, staff training and support and good governance. We completed a targeted inspection on 27 July 2022 to check on good governance and found improvements had been made. At this inspection, we found a number of improvements had been made.

Risk assessments for people were robust and detailed to ensure people received safe care. Risks such as those related to people’s health conditions and mobility were monitored and managed so staff could support them safely. Medicines were managed safely. Safeguarding processes were in place to protect people from the risk of abuse. Staff were recruited appropriately and checked they were of suitable character to support people. There were enough staff working in the home. Systems were in place to prevent and control infections.

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. People were supported to achieve positive outcomes. People were given choices during meal times and were supported by staff when needed.

Staff were kind and caring towards people and had a good relationship with them. People’s dignity, privacy and human rights were respected at all times. Their equality characteristics were understood and respected.

People received care and support that was personalised for their needs. Systems were in place to manage and respond to complaints. People’s communication needs were met. People took part in activities and were supported to see their family and friends.

The management team had implemented robust governance systems and carried out quality audits to ensure the home was compliant with health and social care regulations and to identify areas for improvement. Feedback was sought from people and relatives to help make continuous improvements to the home.

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

Rating at last inspection

The previous rating for this service was Requires Improvement (published 25 November 2021) and there were multiple breaches of regulation. We issued requirement notices for breaches of Regulation 17 (Good Governance), Regulation 11 (Need for consent), Regulation 12 (Safe care and treatment) and Regulation 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

Why we inspected

We undertook this comprehensive inspection to check if there were improvements regarding the concerns we identified at the last comprehensive inspection. The overall rating for the service has changed from Requires Improvement to Good. This is based on the findings at this inspection.

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.

Follow up

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