CQC report explained · a nursing home
What the CQC found at Ash Court Care Centre - Camden
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, April 2021
Ash Court Care Centre - Camden was rated Requires Improvement; medicines management and oversight still had gaps, although inspectors found progress since the previous inspection.
This was an unannounced focused inspection on 02 February 2021. Inspectors checked medicines, safety, management systems and selected areas linked to previous concerns. They reviewed 16 care records and medicines records, spoke with staff, relatives and a health professional, and observed care and medicines administration.
The home had improved since the previous inspection. There were enough staff, recruitment checks were safe, safeguarding concerns were reported, and infection control measures were in place. Care plans were more personalised, and staff training had improved.
However, some medicines were still not managed safely. Records and guidance were missing or incomplete for some medicines, including medicines given when needed, through feeding tubes and covertly. Medicine audits had not found these problems. The overall rating remained Requires Improvement. Safe and Well-led were rated Requires Improvement, while Effective and Responsive were inspected but not rated.
Staffing and recruitment
Inspectors found enough staff on each shift and safe recruitment checks for the staff files reviewed.
“There were enough staff on each shift to support people.” from the report
Safeguarding
Safeguarding concerns and medicine errors were reported to the local authority and the CQC, and staff understood how to raise concerns.
“The provider worked alongside the local authority to investigate all concerns in order to take appropriate action to ensure people were safe.” from the report
Cleanliness and infection control
The home was clean and fresh, with measures in place for PPE, testing, social distancing and preventing infections.
“The home looked and smelled fresh and clean.” from the report
Personalised care planning
Care plans included people's backgrounds, beliefs, relationships and preferences. An electronic system helped staff see updated care information.
“Care planning had further developed since our previous inspection.” from the report
Improved oversight
Managers had introduced several new checks and reports. These usually helped identify and address gaps, apart from the medicine audits.
“There was a range of improved managerial and peer audits introduced.” from the report
Medicine guidance and records
seriousSome people did not have clear or personalised guidance for medicines given when needed. Medicines given through feeding tubes were not correctly recorded, and one person receiving covert medicines did not have pharmacist advice recorded.
“Some people were prescribed medicines such as pain killers and anti-anxiety medicines to be taken on a when required (PRN) basis.” from the report
Medicine storage
seriousFood and fluid thickeners were not always stored securely. Inspectors said this could put people at risk of harm if swallowed.
“Food and fluid thickeners prescribed to people were not always stored securely which put people at risk of harm if they swallowed it.” from the report
Governance checks
seriousThe home had improved its monitoring systems, but medicine audits did not identify the problems found during the inspection. This led to a breach of regulation.
“The provider had carried out medicine audits. However, the audits were not fully effective and had failed to identify concerns we found during the inspection” from the report
Family updates
needs fixingRelatives gave mixed feedback about communication. Some said the home took action after concerns but did not tell them what happened afterwards.
“When any of us have complained to the manager, action seems to follow, but there's never any communication to confirm outcomes.” from the report
End of life planning
minorEnd of life plans had improved, but inspectors said they did not always say when the end of life care pathway should begin.
“End of life care plans needed further development to ensure they specified when the end of life care pathway would be implemented.” from the report
- 01What checks now make sure PRN medicines have clear, personalised instructions for staff?
- 02How are medicines given through feeding tubes recorded and checked to prevent them being given by mouth in error?
- 03How are food and fluid thickeners stored securely now?
- 04How will you tell families the outcome of complaints and agreed improvement actions?
- 05When will the end of life care pathway be started, and how is this recorded in the care plan?
This was a focused inspection of Safe and Well-led, with additional checks linked to previous concerns in Effective and Responsive; the other ratings were not fully reviewed and the Caring rating was not reported. This explanation was written from the published report of 13 April 2021 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, November 2019
Rated Requires Improvement; inspectors found kind care but serious problems with medicines, safeguarding and management.
This was an unannounced inspection on 11 and 12 September 2019. Inspectors spoke with people, relatives and staff, observed care, and checked care, medicines, staff and management records.
The home was caring, and people were generally treated kindly and respectfully. Staff knew people well, supported their choices, provided suitable food and helped people access health professionals. Staffing levels and recruitment checks were also satisfactory.
However, people were not always protected from harm. Medicines were missing or not managed safely, including prescribed medicines that were unavailable for several days. Staff did not always have enough training for specific conditions and clinical tasks. Care plans did not always include people's personal history or end of life wishes.
The overall rating fell from Good at the previous inspection to Requires Improvement. The home breached several regulations. The CQC issued a warning notice about safe care and treatment and said it would monitor an action plan and return to inspect again.
Kind and respectful care
People and relatives gave consistently positive feedback about staff. Inspectors saw attentive care that protected privacy, dignity and independence.
“The feedback from people and relatives about care received at the service was consistently positive.” from the report
Enough staff
Inspectors found enough staff on duty to meet people's needs. Recruitment checks were also completed appropriately.
“There were sufficient staff numbers to support people.” from the report
Food and health support
People's dietary needs and preferences were considered. Staff arranged referrals and worked with health professionals when people's needs changed.
“People were supported to eat and drink enough to maintain a balanced diet.” from the report
Positive relationships
People were supported to make everyday choices and maintain important relationships. Relatives said they were welcomed and could contact managers easily.
“Staff supported people to maintain relationships that were important to them.” from the report
Medicines were unsafe
seriousInspectors found medicines missing, incorrectly recorded or not administered safely. Ten of the 22 people's medicines records reviewed showed missing prescribed medicines, and some people were at serious risk.
“Both people were put at serious risk of being harmed due to not receiving their medicines.” from the report
Safeguarding was not effective
seriousThe home did not record medicine incidents or make safeguarding alerts linked to people missing prescribed medicines. This meant possible harm was not properly identified or reported.
“No safeguarding alerts had been made to the local authority and the CQC.” from the report
Staff training gaps
seriousSome care staff had not received enough training for specific health conditions. A care worker administered insulin without evidence of suitable training or a competency check.
“There was no evidence to show that staff had received appropriate training and that their competences in insulin administration had been checked.” from the report
Weak management checks
seriousAudits failed to identify problems with medicines, safety checks and confidential records. Some roles and responsibilities were unclear, and records were not always stored securely.
“There was a lack of clarity around the level of expectations and accountability when conducting these tasks.” from the report
Care plans lacked personal detail
needs fixingCare plans did not always include people's history, preferences, voice or end of life wishes. Inspectors recommended further training and guidance on person-centred and end of life care planning.
“Care plan records were not always personalised as they lacked information about people's personal lives.” from the report
- 01How do you now make sure every person receives all prescribed medicines on time, especially time-specific medicines and anticoagulants?
- 02What checks now confirm that staff are trained and competent before they administer insulin or carry out other clinical tasks?
- 03How are medicine errors and missed doses recorded, investigated and reported as safeguarding concerns?
- 04How do managers test that their medicines, safety and confidentiality audits identify problems rather than just record high scores?
- 05How have care plans been updated to include each person's history, preferences, voice and end of life wishes?
This was an unannounced inspection covering all five CQC questions, including both the care provided and the care home premises; all five ratings were reviewed and the previous overall rating was Good. This explanation was written from the published report of 6 November 2019 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 Ash Court Care Centre - Camden
4 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- April 2021Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
Read what inspectors found at Ash Court Care Centre - Camden →
- November 2019Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at Ash Court Care Centre - Camden →
- March 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2014
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 18 November 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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At least 100 live-in carers within about an hour of Camden
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £960 to £1,300 a week. 75 can care for a couple. 12 years' experience on average.
“The quality of life that she's given my parents has been priceless. The peace of mind she's given my sisters and I, through a very difficult time, has been invaluable.”
“The interaction she gives my mother is incredible, singing, dancing, taking her to groups, on plenty of walks which mum always loves.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.