Ashurst

Updated 26 September 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

This inspection was carried out by 2 inspectors.

Service and service type

Ashurst 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. Ashurst 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 there was a registered manager in post.

Notice of inspection

We gave the service 24 hours’ notice of the inspection. This was because it is a small service and we needed to be sure that the provider or registered manager would be in the office to support the inspection.

Inspection activity started on 23 August 2023 and ended on 8 September 2023. We visited the location’s office/service on 23 August 2023.

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. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with people to understand their experience of care and support provided. We spoke to 8 staff including the nominated individual, the registered manager, the deputy manager and senior support and support workers. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We reviewed a range of records including 2 people’s care records, medication administration records and associated documentation. We also looked at other records relating to the management of the home and risk management. We looked at safety information and certificates, staff rota’s, accident and incident forms, meeting minutes, audits and policies. We also reviewed 6 staff files in relation to recruitment, staff supervision, competency assessments and training.

Alongside our visit to the service, we used remote technology such as video calls to enable us to engage with staff and electronic file sharing to enable us to review additional documentation.

Updated 26 September 2023

About the service

Ashurst is a small ‘care home’ providing accommodation to up to 5 people who require nursing or personal care. The service provides support to young people with complex mental health needs. At the time of our inspection there were 3 people using the service.

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

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

Right Support: People were supported by staff who had a strong understanding of how to promote people’s independence. Staff supported people to work towards achieving their goals by working in accordance with robust care plans. People told us they felt supported by staff and the management team. People were able to personalise their rooms with personal items important to them; the provider also provided a budget to people so they could choose how their rooms were decorated. The provider consistently reviewed and reflected on the approach staff took in supporting people during times of anxiety and distress to inform continuous improvement.

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.

Right Care: People received support from external healthcare professionals when needed and this was requested in a timely manner. People felt safe at the service and staff’s presence was noted throughout our inspection visit. People’s care and support was tailored around their preferences. Staff had a good understanding of safeguarding and support was provided to people safely. People’s medicines were administered safely; however, record keeping needed improvement. We have made a recommendation relating to medication records.

Right Culture: The provider ensured a person centred approach to care planning, support and care was promoted throughout the service. People’s protected characteristics were considered at all times. The provider had worked proactively with local safeguarding professionals to ensure they were meeting the requirements to share safeguarding incidents in line with local and national guidance and legislation. We observed evidence of reflective work being carried out. The provider had quality assurance systems in place which ensured checks within the service were completed regularly. However, audits were not always consistent with our findings at this inspection. Staff induction records contained significant gaps. We have made a recommendation in relation to governance systems and staff induction records.

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 good (published 7 January 2022).

Why we inspected

We received information which highlighted a review of risk management and service governance was needed. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

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 remained the same.

We found no evidence during this inspection that people were at risk of harm. Please see the safe, effective and well-led sections of this full report.

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.

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

Recommendations

We have found areas where the provider needs to make improvements. We have made recommendations related to medication recording systems, induction records and audits. Please see the safe, effective and well-led sections of this report.