Aynsley Care Centre

Updated 21 July 2022

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

The inspection was completed by an inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Aynsley Care Centre 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. Aynsley Care Centre is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was not a registered manager in post, but a manager had been appointed and had applied to become registered.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed the information we had received about the service and contacted the local authority quality and commissioning teams for their feedback.

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

During the inspection we spoke with the manager and three other members of the staff team. We also spoke with three people that lived in the home and six relatives, most of which were via the telephone.

We reviewed a range of records. This included four people's care records and multiple medication records. We looked at three staff files in relation to safe recruitment. A variety of records relating to the management of the service, including audits were also reviewed.

Updated 21 July 2022

About the service

Aynsley Care Centre is registered to provide accommodation and personal care for up to 28 people. There were 15 people were living there at the time of the inspection, some of whom were living with dementia.

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

The systems in place to monitor the quality and safety of the service were not always effective. They did not highlight all the issues identified during the inspection and it was not always clear if actions had been taken to address identified issues. The manager was not always aware of actions identified on audits, so could not ensure the appropriate steps were taken to improve the quality and safety of the home.

Although improvements had been made regarding the management of medicines, further changes were still required. We made a recommendation regarding the use of homely remedies. There were no homely remedies available to people, which meant there was a risk medicines would not be available to people when they needed them.

Medicines were administered safely by staff who had undertaken training and had their competency assessed. Medication records were completed robustly and showed that medicines were given as prescribed.

People told us they felt safe living in the home. Procedures were in place to ensure safeguarding concerns were reported appropriately. Risks to people and the building had been assessed. Care files showed that measures had been taken to minimise risks to people. Staff knew the people they supported well. Information regarding people’s health conditions was available and advice from other health professionals was reflected within people’s care files. The service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty.

There were enough staff available to meet people’s needs in a timely way. Most safe recruitment procedures had been followed to help ensure staff were suitable to work in social care.

The home appeared clean and well maintained. PPE was available to staff and they had undertaken training to help prevent the spread of infections. Staff were encouraged to undertake regular COVID-19 testing, but there was no system in place to ensure staff tested in line with current government guidance.

Accidents and incidents were reviewed and acted upon to ensure the service acted in a transparent way. People’s relatives were kept informed of any changes regarding their family member and were encouraged to visit the home safely.

Systems were in place to gather feedback regarding the service. Feedback from people and their relatives regarding the care provided and the management of the service was positive. Staff told us they enjoyed their jobs and were well supported by the management team. The manager liaised with other health and social care professionals to help ensure people's needs were met.

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 inadequate (published 18 January 2022) and the provider was found to be in breach of regulations 12 (Safe care and treatment) and 17 (Good governance) of the Health and Social Care Act 2002 (Regulated Activities) Regulations 2008.

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 that some improvements had been made and the provider was no longer in breach of regulation 12 but was still in breach of regulation 17.

This service has been in Special Measures since 17 January 2022. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We carried out an unannounced inspection of this service on 3 December 2021. 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 the governance of the service.

This inspection was carried out to follow up on action we told the provider to take at the last 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.

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.

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 from inadequate to requires improvement based on the findings of this inspection.

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

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.