The Aylsham Manor

Updated 6 April 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

This inspection was carried out by 2 inspectors, 1 medicines inspector and 2 Experts by Experience, 1 on site and 1 making telephone calls to people. 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

The Aylsham Manor 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. The Aylsham Manor is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

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. 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 7 people who used the service and 7 relatives. An additional 3 relatives also provided us with written feedback. One healthcare professional who regularly worked with the service also provided written feedback. We spoke with 8 members of staff including the manager, nominated individual, care and ancillary staff. The nominated individual is responsible for supervising the management of the service on behalf of the provider. A further 9 staff provided us with written feedback.

We reviewed the care records for 9 people who used the service and the medicines administration records for 12 people. We observed the care and support provided and the administration of medicines; the environment was also assessed for safety, cleanliness and suitability. Multiple governance records were reviewed including 3 staff recruitment files, policies, quality assurance audits, maintenance records, risk assessments and training statistics.

Updated 6 April 2023

About the service

The Aylsham Manor is a residential care home providing accommodation and personal care to up to 30 people. The service provides support to older people some of whom may be living with dementia. At the time of our inspection there were 27 people using the service.

The home provides accommodation over 2 floors of a converted period building. There are multiple communal areas and extensive gardens and the home is close to local amenities.

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

The provider had made significant improvements across the service since our last inspection. However, further embedding and additional progress was required. For example, the governance systems in place had not wholly identified and rectified some issues such as gaps in recruitment practices and training and the need for better records in relation to the Mental Capacity Act 2005 (MCA).

People told us the service had a positive impact on their lives and their relatives agreed. People told us they were happier, more confident and felt a sense of belonging living at The Aylsham Manor. Relatives told us the home provided them with peace of mind, confidence in the staff and the knowledge their family members were well cared for. People told us they would recommend the service.

We saw that 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; the policies and systems in the service supported this practice. However, associated records did not always consistently demonstrate this, so the provider needs to ensure this is achieved.

Staff demonstrated the appropriate skills and knowledge to support people in an individualised, respectful and compassionate manner; people told us this and our observations confirmed it. However, there were some gaps in training and the provider needs to ensure this is rectified.

People felt safe living at the service and the associated processes in place helped to achieve this. For example, people received their medicines as prescribed and risks had been identified, managed and mitigated. Improvements had been made in relation to safeguarding practices and we saw the provider was engaging with other professionals appropriately and as required.

People’s needs had been assessed holistically and met on an individual basis. They, their relatives and staff were involved in the service and felt supported and listened to; communication was good. Improvements had been made in recording and analysing accidents and incidents and in the use of reflective practice to further improve the service and reduce future risk.

The culture of the home was positive, nurturing and welcoming. People told us this and our observations confirmed it. Staff felt valued and supported and the people who used the service told us their lives were led happily and with quality.

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 requires improvement (published 12 October 2022) and there were breaches of regulation. 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 improvements had been made and the provider was no longer in breach of regulations. However, the service remains rated requires improvement. This service has either been rated requires improvement or inadequate for the last 5 consecutive inspections.

Why we inspected

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

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.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.