Ashville House

Updated 12 March 2019

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection took place on 29 January 2019 and was unannounced. The inspection was carried out by two inspectors 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. As part of the inspection we reviewed information already known about this service including the last report, notifications which are important events the service is required to tell us about. We reviewed the provider information return. This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make.

As part of our inspection we spoke with eleven people using the service, two care staff, one senior member of staff, the registered manager, the cook and one activity staff. We spoke with four family members and observed the care throughout the day. We reviewed four care plans, daily records and looked at three staff recruitment records, staff files and other records relating the management of the service.

Updated 12 March 2019

We carried out an unannounced inspection to this service on 29 January 2019 and found improvements were required but there were no breaches of the regulations of The Health and Social Care Act 2008. We last inspected this service on 21 and 23 June 2016 and rated it good. Since the last inspection there have been no concerns about the service from other authorities and it has the same registered manager in situ.

Ashville House is a care home. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Ashville House is registered to provide accommodation with personal care to 51 older people. During our inspection visit there were 44 people using the service. The service is situated close to amenities in the town of Downham market and provides both ground and first floor accommodation. There is a chair lift and passenger lift.

There was a registered manager at the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are registered persons. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run.

In summary we found some aspects of the service very positive and other aspects requiring improvements. We found risks from the environment were not always well managed or taken into full consideration when an incident occurred. There were records of incidents, accidents and falls but the information was not fully collated, showing the level of impact or lessons learnt. Record keeping was not as robust as it needed to be which meant we could not clearly evaluate if people always received the care they needed. For example, around their skin care, hydration and nutrition.

Allocated staffing levels were based around people’s dependency levels and for most staffing levels were appropriate. Some people told us however staff were sometimes rushed and call bells not always answered quickly at busier times of the day. Several people were frail and spent most of their time in their room. Their experiences were enhanced by staff spending time with them each day. Some people’s experiences were that staff were busy and sometimes rushed.

Through our observations we saw that additional staff were employed to ensure high standards of cleanliness in the service. There were also activity hours which were used well and clearly benefited people and boosted their well-being. We found people were living well and engaged with all aspects of the service.

Medicines were managed safely and people’s health care needs were monitored and the service was well supported by three different GP practices and other health care professionals. People received nutritional food and lived in comfortable surroundings.

Staff were adequately recruited, trained and supported. Staff worked well together and supported people appropriately. The service was mostly well led and the registered manager well respected.

Staff were trained to recognise abuse and knew what actions to take to promote people’s safety and well-being. Staff spoke with people regularly and gave them opportunities to feedback their experiences of the service.

The service run in the interest of people using it. The service had an established complaints procedure and listened to people’s experiences and could demonstrate how they acted on their feedback. Most people and relatives were complimentary about the service and its management. Staff were kind and respectful and upheld people’s dignity.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. Staff understood actions to take should someone be lacking in mental capacity.