2 March 2023
During an inspection looking at part of 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.