Archived: Ashdale Lodge Residential Care Home

Updated 10 January 2018

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.

This inspection took place on 13 and 22 November 2017 and was unannounced.

Two Adult Social Care Inspectors and an expert-by-experience undertook the inspection. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service. The expert-by-experience had expertise of older people living with dementia.

Prior to the inspection, we contacted the local authority commissioners and safeguarding team to gain their views about the service. We looked at notifications that the provider had submitted to the Care Quality Commission (CQC). Notifications are forms, which the provider has to submit to us by law. They tell us how the provider manages incidents and accidents for people in their care. We also looked at the Enter and View report completed by Healthwatch. The Enter and View report identifies areas of good practice and makes recommendations for improvements.

Before the inspection, the provider completed a Provider Information Return (PIR). 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.

During the inspection, we talked with four people who used the service and five relatives. We also spoke with the regional manager, the registered manager and four members of staff.

We looked at five people’s care records and six medication administration records (MARs). We also used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We observed how staff interacted with people in the communal areas of the service and we completed a tour of the building.

We reviewed how the service used the Mental Capacity Act 2005, to ensure that when people were assessed as lacking capacity to make their own decisions, best interest meetings were held to make important decisions on their behalf.

We saw documentation and records relating to the day-to-day running and management of the service. These included the recruitment information for three members of staff and five supervision and appraisal records. We viewed staff induction and training documentation and staffing rotas. We also looked at the certificates for maintaining equipment, the business continuity plan, and policies and procedures.

After the inspection, we asked the provider to send us further information about the vision and values of the organisation, the statement of purpose and updated behaviour management care plans. This information was received by the requested time, which helped us to make a judgement about the service.

Updated 10 January 2018

Ashdale Lodge Residential Care Home is registered to provide care and accommodation for 37 people, some of whom may be living with dementia. The service has four communal lounge areas, some of which are designated as quiet areas, a dining room, conservatory and a garden. Bedrooms are mainly for single occupancy but there are three shared rooms for couples or people who wish to share. The service is situated about a mile west of Hull City Centre and is close to a range of community facilities. It is on major bus routes and has a small carpark.

At the last inspection on 19 October 2015, the service was rated Good. At this inspection, we found the service remained Good. This inspection took place on 13 and 22 November 2017 and was unannounced.

At the time of our inspection, 30 people were using the service and there was a registered manager in post. 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.

We found best interest meetings did not always include all relevant people and did not always consider least restrictive options. We have made a recommendation for the provider to use the Mental Capacity Act 2005 code of practice to inform their policies and procedures regarding best interest decision-making.

People told us they felt safe living at the service. Staff were clear about their responsibilities to protect people from the risk of harm and abuse, and had completed training in safeguarding vulnerable people.

People received their medications as prescribed. However, the provider had recently identified issues in the recording of medicines and had put steps in place to reduce the reoccurrence of this.

People’s nutrition and health needs were met. Referrals to healthcare professionals were completed in a timely manner and people were involved in making decisions regarding their own treatment and care where possible.

Although some care plans were not fully up-to-date, staff were responsive to people’s needs and we found no detrimental impact on people. Pre-admission assessments enabled staff to provide care for people from the day of their admission and assessments were person-centred.

We found staff were recruited safely and received an induction, which was linked to the Care Certificate. Staff received training, supervision and appraisal as required, and there were sufficient staff on duty to meet people’s individual needs. Staff were trained in infection control and the service was safe, clean and tidy. Business continuity plans and personal emergency evacuation plans (PEEPs) gave staff clear guidance on how to keep people safe in the event of emergencies.

The environment supported people who were living with dementia and catered for people’s individual needs. We saw the décor, activities and many communal areas enabled people to spend time as they wished. Activities were tailored to people’s needs and preferences. Newsletters kept people updated with relevant information.

We found people were supported by staff who were caring, patient and compassionate. People were treated with dignity and respect, and were enabled to be independent. There were no restrictions on visits, and accessing the community was encouraged. Local community groups, such as schools, were invited to the service and there had been a recent open day where the community could attend the service.

We found the culture of the provider to be open and inclusive. Comments regarding the provider and registered manager were positive, and everyone said that they were approachable. People told us any complaints would be addressed and we saw the provider had responded to feedback. The registered manager understood and fulfilled their duty to report notifiable incidents to the Care Quality Commission as required under legislation. The provider had developed quality assurance and governance systems to highlight shortfalls and drive improvements within the service.

Further information is in the detailed findings below.