Ashgrove House

Updated 29 January 2022

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

As part of CQC’s response to the COVID-19 pandemic we are looking at how services manage infection control and visiting arrangements. This was a targeted inspection looking at the infection prevention and control measures the provider had in place. We also asked the provider about any staffing pressures the service was experiencing and whether this was having an impact on the service.

This inspection took place on 20 January 2022 and was announced. We gave the service 24 hours’ notice of the inspection.

Updated 29 January 2022

The inspection of Ashgrove House took place on 16 October 2018 and was unannounced. At the previous inspection in September 2017 we found an issue with medication which was swiftly dealt with. As this was a breach of the Health and Social Care Act regulations the home was rated requires improvement. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions, safe and well led, to at least good. On this inspection we found significant improvement had been made.

Ashgrove House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Ashgrove House accommodates 30 people in one adapted building. During this inspection there were 27 people living at Ashgrove House.

There was a registered manager in post on the day of the inspection and we spent time with them. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People and relatives told us they felt safe and secure at Ashgrove House. This was because they knew all the staff, many of whom had been at the home some time, and also because they felt staff were well trained and knowledgeable. They also felt there were sufficient numbers of staff.

Risks were managed according to individual need and we saw staff support people safely and appropriately with transfers. These were supported with detailed risk assessment and management plans which were regularly reviewed. There were few accidents in the home but those that did occur were properly assessed and reviewed to ensure all possible risk reduction measures were in place, and lessons learned were shared.

Medication was administered, recorded and stored safely, and people’s medication needs were regularly assessed with the support of the local GP who had established a weekly surgery in the home. This ensured any issues were dealt with promptly. Staff were aware, and practised, effective infection control reducing the likelihood of harm.

Best practice principles were adhered to and known as they were fed through the Director of Care, who attended many good practice forums. The registered manager was experienced and shared their knowledge and led by example. Staff had access to regular supervision and training, and were supported by newsletters and meetings of changes in policy or procedures.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People had effective nutritional and hydration support and staff were attentive to people’s differing abilities. They encouraged people to be independent as far as possible, and promoted choice and involvement. Teamwork was evident in the home and staff were extremely supportive of each other, to the extent if any were ill, they would cover for each other. There was a strong commitment to person-centred care and staff supported people discreetly and sensitively, always mindful this was people’s home.

The home was in the midst of a significant extension but had utilised as much as possible of the outdoor space, including the building of a large decked area accessible through the lounge.

Staff were consistently kind, patient and compassionate with people, and clearly knew all residents well. They were involved in reviews of people’s care needs and responded to changes quickly and appropriately to ensure the person had the maximum quality of life. People’s privacy and dignity was promoted.

The provision of activities was extensive and reflected people’s preferences. The activity co-ordinator oozed enthusiasm and commitment and was constantly seeking to incorporate new ideas.

Care records were thorough, detailed and reflective of the individual they pertained to. They were regularly reviewed and amended as needed. The evidence of so many compliments showed the appreciation the staff and management were given.

The atmosphere was positive, welcoming and very friendly. People were settled and calm, enjoying each other’s company and interactions with staff in equal measure. The registered manager was visible, and extremely supportive of their staff showing understanding and compassion at all times. People spoke positively of the links they had with the local nursery.

The provider and senior management team were committed to providing the highest possible standard of care and this was demonstrated in robust audits, which were honest and unflinching in their quest for perfection.