CQC report explained · a residential care home
What the CQC found at A S Care
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Staffing was enough to meet care needs but care staff had to do housekeeping and catering tasks when those staff were absent. Some cleaning and maintenance issues remained, such as rusty equipment and stained walls.
- Effective?
- Requires improvement
- The home did not fully follow the Mental Capacity Act regarding giving medicines covertly. Assessments and best interest decisions were not properly recorded. Staff were trained and people’s health needs were monitored.
- Caring?
- Good
- Are people treated with kindness and dignity?
- Responsive?
- Requires improvement
- Is care built around the person? Care plans, activities, complaints.
- Well-led?
- Requires improvement
- Managers improved audits and oversight, but they had not identified the ongoing issues with covert medicines. The culture was open and people felt able to make choices and raise concerns.
What inspectors found, September 2023
Rated Requires Improvement; inspectors found some safer care and better management but concerns remain about covert medicines and staffing roles.
Inspectors visited A S Care, a residential home for up to 25 older people, including those with dementia and physical disabilities. They checked how safe, effective, and well-led the home was, focusing on areas where problems had been found before.
They found that while some improvements had been made, such as better medicine management and staff recruitment, the home still did not fully follow the law about giving medicines hidden in food or drink without a person's knowledge. This is important to make sure care is lawful and in people's best interests.
Staffing levels were enough to meet people's care needs, but care staff had to cover housekeeping, laundry, and catering tasks when those staff were not present. The home was working on improving cleaning and maintenance, but some areas like the garden were not well kept.
People said they felt safe and cared for by kind staff. The managers had improved checks and audits to spot problems sooner. However, the home still needs to improve how it follows the Mental Capacity Act and how it supports people to make decisions about their care.
Improved medicine management
The home improved guidance and training for managing diabetes and oxygen therapy, making medicine use safer.
“Improvements to guidance on monitoring blood sugar levels and the associated administration of insulin had improved.” from the report
Enough care staff
There were enough trained care staff to meet people’s needs and respond to call bells promptly.
“People told us there were enough staff to meet their needs, and that staff answered requests for assistance, including call bells in a timely manner.” from the report
Better quality checks
Managers improved audits and monitoring to spot problems quickly and take action.
“The frequency and complexity of audits had improved to enable shortfalls to be noted more quickly so as action could be taken to bring about improvement.” from the report
Covert medicine practices
seriousMedicines given without people’s knowledge were not always managed according to the law and best interest decisions were not properly recorded.
“The principles of the Mental Capacity Act 2005 had not been fully implemented with regards to people's medicine. Assessments to determine people's capacity to make informed decisions about declining their medicine had not been undertaken.” from the report
Cleaning and maintenance issues
needs fixingSome areas were not well cleaned or maintained, such as rusty radiators and stained walls, which could increase infection risk.
“A radiator in shower room and a trolley in the dining room were rusty. This prevents effective cleaning and increases the risk of infection spreading.” from the report
Garden not well maintained
minorThe garden was not well cared for, with weeds and no colourful plants, limiting people’s enjoyment of outside space.
“The garden was not well-maintained, with weeds growing in the beds and borders. There were no raised beds or plants providing colour.” from the report
- 01How do you ensure medicines given without a person's knowledge are managed lawfully and in their best interests?
- 02What arrangements are in place so care staff are not distracted by housekeeping, laundry, or catering duties?
- 03How do you keep the home clean and maintain equipment to reduce infection risks?
- 04What plans do you have to improve the garden and outside spaces for residents?
- 05How do you involve people living here in decisions about their care and the running of the home?
This was a focused inspection looking at Safe, Effective and Well-led key questions following previous concerns. This explanation was written from the published report of 13 September 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, June 2023
Rated Requires Improvement; inspectors found important safety, care planning and management problems, although the home improved and left special measures.
This was an unannounced focused inspection on 22 and 23 May 2023. Inspectors checked whether the home had acted on its previous improvement plan. They spoke with people, relatives, staff and health professionals, and reviewed care plans, medicines records, staff files and management records.
There were ongoing risks with diabetes care, including insulin records and instructions. Care plans were not always current or consistent. Staff recruitment checks were incomplete, deep cleaning was not always carried out, and some staff did not understand whistle-blowing. People were not always supported in line with conditions attached to their Deprivation of Liberty Safeguards.
The home had improved its building, staffing levels, some medicines processes and safeguarding records. People and relatives generally said they felt safe, staff were kind and approachable, and food was good. However, the provider's checks had not found or fixed some important problems, so the home remained in breach of four regulations.
The overall rating improved from Inadequate to Requires Improvement. The home was no longer in special measures, but CQC said there was still limited assurance about safety and that more improvement was needed.
Improved environment
The building and its upkeep had improved significantly since the previous inspection. Wardrobes were secured, emergency call buttons worked and window restrictors were in place.
“At this inspection significant improvements had been made to the environment and upkeep of the building had improved.” from the report
Enough staff
Inspectors found enough suitably qualified staff and observed that people's needs were answered promptly. Some relatives had concerns about weekend staffing, but the rota showed enough staff.
“There were sufficient suitably qualified, competent, and skilled staff employed.” from the report
Kind and approachable staff
People and relatives spoke positively about staff and the registered manager. Relatives said communication had improved and that they were kept involved in care.
“People and relatives spoke positively about the registered manager and staff.” from the report
Food and choice
People were happy with the quality and choice of food. People who needed help to eat were supported in a person-centred way.
“People were happy with the choice and quality of the food.” from the report
Improved medicines processes
Guidance for as-needed medicines had improved, medicine room temperature problems were not found again, and allergies were recorded.
“At this inspection this has improved, and appropriate guidance was in place.” from the report
Unsafe diabetes care
seriousInsulin was not always given correctly, including when blood sugar was too low. Care plans and staff knowledge did not always give safe instructions for diabetes or other emergencies.
“Diabetes was not always managed safely.” from the report
Poor management checks
seriousAudits did not reliably identify or resolve risks. Problems with diabetes care, repositioning records and fluid records were missed or remained after earlier checks.
“The systems had not been successfully embedded to assess, monitor and mitigate risks to the health, safety and welfare of people using the service.” from the report
Incomplete recruitment checks
seriousSome staff records did not include a full employment history and suitable references were not always obtained. CQC said this was a repeat breach.
“Staff recruitment was not always safely completed.” from the report
DoLS conditions not followed
seriousThe home did not always complete required analysis of distress behaviours. This meant some people were deprived of their liberty without the required actions being taken.
“As people were not always supported in line with their DoLS conditions, people were not always safeguarded from improper treatment.” from the report
Infection control shortfalls
needs fixingDeep-cleaning rotas had not been completed, and mop heads were not washed regularly between changes. This left people at ongoing risk of infection.
“There was a lack of deep cleaning taking place at the location.” from the report
Consent and best-interest records
needs fixingRecords did not always show who had been involved in best-interest decisions. Staff did not always ask permission or explain everyday care before carrying it out.
“Staff did not always ask people for consent with day-to-day tasks to make sure they were happy to be supported.” from the report
- 01What changes have you made to ensure insulin is given correctly and diabetes care plans are updated immediately?
- 02How do you check that staff understand what to do when someone's blood sugar or oxygen level is unsafe?
- 03What evidence can you show that all staff recruitment files now contain full employment histories and suitable references?
- 04How are DoLS conditions and best-interest decisions recorded and checked?
- 05How often are deep cleaning and care-record audits now completed, and who checks that identified problems have been fixed?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not assessed or rated, and the report's overall rating changed from the previous comprehensive inspection. This explanation was written from the published report of 23 June 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of A S Care
10 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- September 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2023Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- March 2023Inadequatedown from Requires improvementSafe: InadequateWell-led: Inadequate
- December 2021Requires improvementSafe: Requires improvementWell-led: Requires improvement
- May 2021Inspected but not ratedSafe: Inspected but not rated
- February 2018Goodup from Requires improvementSafe: GoodEffective: GoodResponsive: GoodWell-led: Good
- August 2017Requires improvementstayed Requires improvementSafe: Good
- March 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2017Requires improvementstayed Requires improvementWell-led: Inadequate
- October 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- November 2015Requires improvementSafe: GoodEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 13 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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