CQC report explained · a residential care home
What the CQC found at Ardsley House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Inspectors were assured that the home was following safe infection prevention and control procedures. They checked visitors, admissions, protective equipment, testing, hygiene, outbreak management and the infection control policy.
- Effective?
- Good
- This question was not assessed in this targeted inspection.
- Caring?
- Good
- This question was not assessed in this targeted inspection.
- Responsive?
- Good
- This question was not assessed in this targeted inspection.
- Well-led?
- Good
- This question was not assessed in this targeted inspection.
What inspectors found, December 2020
Ardsley House was inspected but not rated; inspectors were assured that infection prevention and control measures were in place.
This was an announced, targeted inspection on 30 October 2020. It looked only at infection prevention and control during the coronavirus pandemic.
Inspectors found good practice. Visitors completed a COVID-19 risk assessment and declaration, had their temperature checked, and staff had checks on using protective equipment. People and staff could also access regular COVID-19 testing.
The inspectors were assured that the home was managing infection risks, including visitors, admissions, protective equipment, testing, cleanliness, outbreaks and its infection control policy. The service was inspected but not rated, so this report does not give an overall quality rating.
Visitor safety checks
Visitors completed a COVID-19 risk assessment and declaration and had their temperature checked before entering.
“Visitors had to sign a COVID-19 risk assessment and declaration before entering the building and had their temperature checked on entry.” from the report
Protective equipment
The home checked that staff were competent in putting on and taking off protective equipment.
“The home completed PPE competency checks on all staff to ensure they were competent in donning and doffing PPE.” from the report
Testing access
People living at the home and staff had access to regular COVID-19 testing.
“People and staff had access to regular COVID-19 testing.” from the report
Support with understanding COVID-19
Staff used easy-read information and meetings to discuss COVID-19 and reduce anxiety.
“Staff used easy read materials and meetings to discuss COVID-19 and reduce anxieties around COVID-19, with people who used the service.” from the report
Inspectors raised no specific concerns in this report.
- 01What infection prevention and control arrangements are in place now?
- 02How do you check that staff can use protective equipment safely?
- 03How often are people living here and staff tested for infections?
- 04How do you explain infection risks and changes in routines to people with learning disabilities?
- 05How do you manage visitors and new admissions safely?
This was a targeted inspection of infection prevention and control during the coronavirus pandemic; it did not assess the other four key questions or give an overall rating. This explanation was written from the published report of 4 December 2020 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, February 2020
Ardsley House was rated Good overall, but inspectors found that medication records and some risk assessments needed improvement.
This was an unannounced inspection on 3 February 2020. Inspectors spoke with six people, three relatives, five staff and one healthcare professional. They observed care and checked records, medicines, staff files and the home's monitoring systems.
People said they felt safe and were happy living in the home. Staff knew people well, supported their independence and helped them access healthcare, activities and meals suited to their needs. Inspectors saw kind and respectful care, good communication and positive management.
The Safe rating fell from Good to Requires Improvement. Records for some as-needed medicines and thickening medicine were not detailed enough. Some risk assessments also needed more information. The overall rating stayed Good, with the other four areas rated Good.
Kind and respectful care
Inspectors observed kind, patient and respectful interactions. People and relatives gave positive feedback about staff.
“We observed positive interactions between people and staff and people seemed very relaxed and enjoying staff's presence.” from the report
Promoting independence
People were encouraged to cook, take part in household tasks and, where safe, manage their own medicines.
“People's independence was promoted. For example, the service had developed a weekly pictorial board with the names of people who were involved in communal household tasks and cooking.” from the report
Staff knew people well
Many staff had worked at the home for several years. Inspectors found that staff understood people's needs, preferences and communication styles.
“Most staff had been working in the service for several years and knew people's needs and preferences very well.” from the report
Activities and community life
People took part in activities they chose, both at home and in the community, including gardening, cooking, pottery and outings.
“People were involved in regular activities of their interest and preference, in the house and out in the community.” from the report
As-needed medicine records
needs fixingProtocols did not give enough detail about the signs staff should look for before giving as-needed medicine. Some people had taken this medicine for more than a week without a GP review, contrary to the provider's policy.
“Protocols for 'as and when required' (PRN) medication required further detail in relation to the signs staff should look out for when considering if people needed that medication.” from the report
Thickening medicine records
seriousRecords did not clearly state how thickening medicine should be given or how many scoops were added to drinks. This affected people who needed thickened drinks to reduce choking risks.
“Improvements were also required in recording the number of scoops of thickener added to people's drinks each time this support was provided.” from the report
Risk assessment detail
needs fixingSome risk assessments did not fully describe known health risks or the actions staff were taking. Inspectors found no evidence that this had harmed people, and the manager acted to review the records.
“However, we found examples when further details were required in people's risk assessments.” from the report
Audits missed recording problems
needs fixingThe home carried out monthly medicine audits, but these had not identified the problems with as-needed medicine and thickening medicine records.
“However, issues related with PRN medication or use of thickeners had not been identified in recent medication audits.” from the report
- 01What changes have been made to the records and protocols for as-needed medicines?
- 02How do you record the number of scoops of thickener added to each person's drinks?
- 03How do you check that people taking as-needed medicine for more than a week receive a GP review?
- 04How have risk assessments been updated for people with skin integrity or other ongoing health risks?
- 05How do your medicine audits now check the issues identified in this inspection?
This was an unannounced planned inspection covering all five CQC questions, with observations, discussions and checks of records for three people. This explanation was written from the published report of 14 February 2020 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 Ardsley House
3 rated inspections over 5 years: the service has held its Good rating throughout.
- December 2020Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- February 2020Goodstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- March 2011
Report published without a new overall rating.
- March 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 8 December 2010.
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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