28 June 2023
During an inspection looking at part of 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.