Archived: Ashlea Mews

Updated 6 May 2017

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 22 and 23 March, the first day was unannounced. This meant the registered provider did not know we were coming.

The inspection was carried out by one adult social care inspector and an expert by experience who spoke to people and relatives to gain their opinions and views of the service. An expert by experience is a person who had personal experience of using or caring for someone who used this type of service.

Before the inspection we reviewed other information we held about the service and the provider. This included previous inspection reports and statutory notifications we had received from the provider. Notifications are changes, event or incidents the provider is legally obliged to send to CQC within required timescales. We also contacted the local Healthwatch, the local authority commissioners for the service, the local authority safeguarding team and the clinical commissioning group (CCG). Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England.

During our inspection we spoke with 11 people who lived at Ashlea Mews. We spoke with the registered manager, the deputy manager, four care workers, the activities coordinator and catering staff who were all on duty during the inspection. We spoke with a GP, one social care worker and one health care professional who was visiting the home. We also spoke with five relatives of people who used the service.

We carried out some observations using 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 looked around the home and viewed a range of records about people’s care and how the home was managed. These included the care records of three people, the recruitment records of three staff, training records, and records in relation to the management of the service.

Updated 6 May 2017

This inspection took place on 22 and 23 March 2017. The first day of the inspection was unannounced. This meant the staff and registered manager did not know we would be visiting.

Ashlea Mews Residential Home provides personal care and accommodation for 40 older people. The service was supporting 39 people at the time of this inspection.

The service had a registered manager. 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.

Food and fluid charts were not fully completed, target amount of fluids were not recorded. Where people had refused meals, there were no records to suggest staff had returned at a later time to offer food again.

We have made a recommendation about maintaining records regarding people’s nutritional needs.

There were robust recruitment processes in place with all necessary checks completed before staff commenced employment.

There were systems in place to keep people safe. We found staff were aware of safeguarding processes and knew how to raise concerns if they felt people were at risk of abuse or poor practice. Accidents and incidents were recorded and monitored as part of the registered manager’s audit process.

The registered provider used a dependency tool to ascertain staffing levels. We found staffing levels to be appropriate to meet needs of people who used the service. These were reviewed regularly to ensure safe levels. Call buzzers were answered in a timely manner and staff were visible throughout the building.

Medicines were administered by trained staff who had their competencies to administer medicines checked regularly. Medicine administration records (MAR) were completed with no gaps, medicine audits were completed regularly. Policies and procedures were in place for safe handling of medicines for staff to refer to for information and guidance.

Staff training was up to date. Staff received regular supervision and an annual appraisal. Opportunities were available for staff to discuss their performance and development.

People were supported by kind and attentive staff, in a respectful and dignified manner. Staff discussed interventions with people before providing support. Advocacy services were advertised in the foyer of the service accessible to people and visitors. Staff knew people's abilities and preferences, and were knowledgeable about how to communicate with people.

People’s nutritional needs were assessed and we observed people enjoying a varied diet, with choices offered and alternatives available. Staff supported people with eating and drinking in a safe, dignified manner.

Care plans were individualised and person centred focussing on people's assessed needs. Plans were reviewed and evaluated regularly to ensure planned care was current and up to date.

People were supported to maintain good health and had access to healthcare professionals when necessary and were supported with health and well-being appointments.

The registered provider had an activity planner with a range of different activities and leisure opportunities available for people.

The registered provider had a quality assurance process in place to ensure the quality of the care provided was monitored. People and relative’s views and opinions were sought and used in the monitoring of the service. Processes and systems were in place to manage complaints.

The service adhered to the principles of the Mental Capacity Act and had made applications to the appropriate agencies to deprive people of their liberty and keep them safe.

The registered provider ensured appropriate health and safety checks were completed. We found up to date certificates to reflect fire inspections, gas safety checks, and electrical wiring test had been completed.

A business continuity plan was in place to ensure staff had information and guidance in case of an emergency. People had personal emergency evacuation plans in place that were available to staff.