Background to this inspection
Updated
25 November 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.
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 carried out by 1 inspector.
Service and service type
Aykroyd Lodge 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. Aykroyd Lodge 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 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 not a registered manager in post. A new manager had been in post since August 2023 and had submitted an application to register. We are currently assessing the application.
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 1 person who uses the service and 1 relative about their experience of the care provided. We spoke with 7 staff including the manager, operations manager, deputy manager and care workers. We also observed how staff provided support for people to help us better understand their experiences of the care they received.
We had a tour of the building with the manager. We reviewed a range of records including records relating to medicines, staff recruitment, building maintenance, cleaning and equipment checks, accidents and incidents and safeguarding logs. We also looked at a variety of records relating to the management of the service including audits and policies and procedures.
Updated
25 November 2023
About the service
Aykroyd Lodge is a residential care home providing accommodation and personal care to up to 5 people with a learning disability. At the time of our inspection there were 3 people living at the home.
People’s experience of using this service and what we found
We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.
Right Support
Risks to people’s safety were not always managed and recorded well. 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. However, the policies and systems in the service did not always support this practice as capacity assessments and consent to care forms had not been reviewed or updated for a long period of time. We made a recommendation about this. Improvements were needed to the environment to ensure it was suitable for the people living at this service. There were enough skilled and experienced staff to safely care for people and recruitment processes were safe. We were assured IPC practices were safe. Staff supported people with their dietary requirements and to enjoy meaningful activities. Staff treated people with dignity and respect.
Right Care
Medicines were mostly being managed safely. However, we identified shortfalls in this area. We made a recommendation about this. People’s needs were assessed prior to them starting to use the service. However, care plans required work to ensure they were person centred and reflective of people’s current needs. We made a recommendation about this. Although nobody at the service was receiving end of life care, records identified people’s advanced decisions. People were treated well, and their individuality was respected.
Right Culture
Governance systems were not always effective at improving the quality and safety of the service. Audits did not always identify concerns, and when concerns were found, there was limited evidence of what action was taken. There was a complaints procedure in place, but concerns were not always formally logged to identify trends and themes. Staff attended meetings and had regular supervisions. Staff were aware of their safeguarding responsibilities and felt comfortable raising concerns. People’s communication needs were considered. Staff and relatives spoke positively of the manager.
For more details, please see the full report for Aykroyd Lodge which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 17 January 2018)
Why we inspected
This inspection was prompted by a review of the information we held about this service.
Enforcement and Recommendations
We have identified breaches in relation to the risks of the health and safety of the people living at this service and good governance. We made recommendations in relation to medicines, consent, and care plans.
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.