Ashbourne Court Care Home

Updated 22 July 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.

Inspection team

The inspection was carried out by 1 inspector.

Service and service type

Ashbourne 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. Ashbourne Court Care Home 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

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 4 people who used the service about their experience of the care provided. We spoke with 2 members of staff including the registered manager and team leader and met the activities coordinator and a care worker.

We reviewed a range of records. This included 5 people’s care records. We looked at 4 staff files in relation to recruitment and staff supervision. We looked at how the provider was managing risk in the service including incidents and accidents. 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 staff rotas and quality assurance records. We contacted and received feedback from 3 relatives and 4 staff members. We received feedback from 2 professionals who regularly visit the service.

Updated 22 July 2023

About the service

Ashbourne Court Care Home is a care home providing personal care over 2 floors to up to 16 people. The service provides support to older people, some of whom were living with dementia. At the time of our inspection there were 15 people using the service.

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

The staff received training in the administration of medicines and had their competencies assessed. However, we found some staff did not always follow the provider’s medicines policy and procedures. We identified some shortfalls on the day of our inspection.

The process for learning from accidents and incidents to prevent these from happening again was inconsistent. Some accident records were incomplete and did not contain evidence of an analysis on what happened and how to prevent re-occurrence.

The provider had monitoring systems in place and took prompt action when any concerns were identified. However, their systems had not identified the concerns we found during our inspection. Following our feedback, the registered manager provided evidence they had taken appropriate action to make improvements.

Staff were recruited safely. There was enough staff on duty to meet people's needs and these were met in a timely manner. There was a calm and happy atmosphere. People told us the staff responded to calls and met their needs. The provider had contingency plans in place in the event of staff absence to help ensure continuity of care.

There were risk assessments in place for people who used the service and the environment which were regularly reviewed and updated. Safety checks were undertaken regularly including fire safety and environment checks.

A part-time activities coordinator provided people with a range of activities and people spoke highly of them.

Feedback indicated people using the service were happy with the care they received. We saw the staff were kind and friendly. Relatives thought people were well cared for and trusted the staff and management team.

The provider was suitably qualified and experienced. They worked with staff to ensure people’s needs were met in a person-centred way. There were appropriate systems for reviewing people's health and working with relevant health and social care professionals.

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

The last rating for this service was good (published 28 August 2019).

At our last inspection we recommended that the provider ensures sufficient staff are consistently deployed in order to provide people with safe, effective and responsive care. At this inspection, we found that improvements had been made.

Why we inspected

We received intelligence in relation to an increase in safeguarding concerns. As a result, we undertook a focused inspection to review the key questions of safe 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 changed to requires improvement based on the findings of 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.