18 April 2023
During an inspection looking at part of the service
Ashfield (Malton) is a residential care home providing personal and nursing care to up to 31 people. The service provides support to older people. At the time of our inspection there were 16 people using the service.
People’s experience of using this service and what we found
A governance framework was in place however this was not robust as it failed to identify the concerns we found during inspection. There was a lack of consistency and discrepancies in documentation relating to some aspects of the service. Quality assurance information to support and evaluate learning and improvement had commenced but was not yet fully embedded. The registered manager and deputy manager had started to review and allocate responsibilities.
Detailed risk assessments meant risks to people were monitored and managed, however on the day of our visit the number of personal emergency evacuation plans (PEEPs) did not match the number of people living at the home because 1 person had been admitted to hospital that week.
Staff were knowledgeable about how to keep people safe and felt confident to report concerns to seniors and managers should they arise. Sufficient numbers of suitable staff were employed, and care was observed to be unhurried. Medicines were administered safely, and current guidelines and protocols were followed. People were protected by the prevention and control of infection. The home was clean, tidy and odour-free.
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 did not support this practice. This is because Deprivation of Liberty Safeguards had sometimes been made when it was recorded the person had capacity.
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 requires improvement (published 8 April 2022). The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections. The provider completed an action plan after the last inspection to show what they would do and by when to improve.
At this inspection we found the provider remained in breach of regulations.
Why we inspected
We carried out an unannounced focused inspection of this service on 25 and 31 January and 4 February 2022. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment and good governance.
We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements. 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 remains the same. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Ashfield (Malton) on our website at www.cqc.org.uk.
Enforcement
We have identified breaches in relation to how managers tracked and monitored risk and used quality assurance audits to ensure systems and processes were followed correctly at this inspection.
Please see the action we have told the provider to take at the end of this report.
Follow up
We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.