CQC report explained · a residential care home
What the CQC found at Ash Grove
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People told inspectors they felt safe. Risks, medicines and infection control were managed well, but inspectors found shortfalls in the recruitment of new staff.
- Effective?
- Good
- People's needs were assessed, staff were trained and people were supported with food, drink and healthcare. This rating improved from Requires Improvement at the last comprehensive inspection.
- Caring?
- Good
- This question was not inspected during this focused visit. The previous rating was carried forward when calculating the overall rating.
- Responsive?
- Good
- This question was not inspected during this focused visit. The previous rating was carried forward when calculating the overall rating.
- Well-led?
- Good
- The management team monitored quality, supported staff and encouraged people to raise concerns. People asked for more ways to give feedback, and the manager agreed to increase residents' meetings.
What inspectors found, December 2021
Ash Grove rated Good; inspectors found safe, kind and effective care, with recruitment checks needing improvement.
This was an unannounced focused inspection on 15 and 16 November 2021. One inspector reviewed records, toured the home, observed care and spoke with people, staff, managers and a healthcare professional.
The home was rated Good overall. Safe, effective and well-led were rated Good. Inspectors found people felt safe, staff were kind and helpful, medicines were managed safely, and people's health, nutrition and personal choices were supported.
Inspectors did find shortfalls in the recruitment of new staff. The provider took immediate action and sent a plan explaining what it would do. People also wanted more opportunities to give feedback, so the manager agreed to hold residents' meetings more often.
People felt safe
People told inspectors they felt safe and were happy with the care. Staff understood how to respond to safeguarding concerns.
“People told us they felt safe living in the home, and they were happy with the service provided.” from the report
Kind and respectful care
Inspectors found friendly and respectful relationships. Staff knew people well and supported their dignity, choices and personal preferences.
“Management and staff had developed friendly, caring and respectful relationships with people living in the home.” from the report
Safe medicines support
Medicines were stored and managed safely. Staff were trained and records covered receiving, giving and disposing of medicines.
“Medicines were stored and managed safely. Staff were suitably trained to administer medicines and checks on their practice had been carried out.” from the report
Good support and training
People's needs were assessed before they moved in. Staff received induction, mandatory training, supervision and appraisals.
“New staff were supported through an induction programme and the provider's mandatory training was provided for all staff members.” from the report
Quality monitoring
The management team used audits, checks and action plans to monitor the service and address shortfalls.
“The provider had established effective systems to monitor the quality of the service.” from the report
Recruitment checks
needs fixingInspectors found shortfalls in the recruitment of new staff. The provider took immediate action and sent a plan describing the intended improvements.
“Whilst the provider had an established recruitment procedure, we found shortfalls in the recruitment of new staff.” from the report
Consent records
minorThe electronic care planning system did not allow people to sign to show consent to care. The deputy manager agreed to upload signed paper forms.
“However, there was no facility for people to sign to indicate their consent to care on the electronic care planning system.” from the report
Opportunities for feedback
minorPeople asked for more ways to express their views. The manager agreed to increase residents' meetings and widen the Resident of the day programme.
“People spoken with asked for more ways to express their views.” from the report
- 01What recruitment checks were found to be incomplete or otherwise short of the required standard?
- 02What immediate action was taken after the recruitment shortfalls, and has the action plan now been completed?
- 03How will signed consent forms be stored and kept up to date?
- 04How often are residents' meetings now held, and how are suggestions followed up?
- 05What were the previous ratings for caring and responsive care, which were not reassessed during this inspection?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 1 December 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, January 2021
Victoria Care Home was rated Good after improvements, with inspectors finding safe, responsive and well-led care but some medicine records still needed better recording.
This was a focused inspection on 16 December 2020. It was announced with 24 hours' notice because of COVID-19 restrictions. Inspectors observed care, spoke with people and staff, toured the home and checked care, medicine, recruitment and management records.
The home was rated Good for Safe, Responsive and Well-led. Inspectors found enough staff, safe recruitment, appropriate infection control, clear care plans, activities and ways for people to raise complaints. People said they felt safe and staff were kind and caring.
The inspection followed an earlier Requires Improvement rating and two breaches about medicines and staffing. Inspectors found enough improvement for the home to no longer be in breach. Some recording of thickening agents and prescribed creams still needed improvement.
Improved medicines management
The problems found at the previous inspection had been addressed, and medicine records and risk assessments were clearer.
“Medicine records were clear and accurate, and each person had a medicine risk assessment with personalised care information.” from the report
Enough staff
Inspectors found enough staff during the visit, and the home had systems to monitor staffing levels.
“We observed there were enough staff on duty during the inspection.” from the report
Personalised support
Care plans reflected people's needs and preferences. Staff knew people well and responded to changing needs.
“Each person had an individual care plan, which was reflective of their current needs.” from the report
Family contact and activities
During the pandemic, the home helped people keep in touch with relatives and provided individual and group activities.
“Staff supported people to maintain relationships with their friends and families during the pandemic.” from the report
Quality improvement
The home used audits, meetings, feedback and training to track improvements following the previous inspection.
“The provider completed an action plan after the last inspection to show what they would do and by when to improve.” from the report
Some medicine records needed improvement
needs fixingInspectors said recording of people's thickening agents and prescribed creams needed improvement. The manager said this would be addressed immediately.
“Some improvement was required with recording of people's thickening agents and prescribed creams.” from the report
- 01How do you now record thickening agents and prescribed creams, and how do you check that records are complete?
- 02What changes were made after the previous breaches relating to medicines and staffing?
- 03How do you monitor staffing levels when people's needs change or staff are absent?
- 04How will you support my relative to maintain contact with family and take part in activities?
- 05When were the Effective and Caring areas last fully assessed, and what were their ratings?
This was a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not looked at and their previous ratings were carried forward. This explanation was written from the published report of 8 January 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.
Every inspection of Ash Grove
8 rated inspections over 7 years: the service has improved, from Inadequate to Good.
- December 2021Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2021Goodup from Requires improvementSafe: GoodWell-led: Good
- March 2020Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2019Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2017Requires improvementstayed Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2015Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Good
- April 2015InadequateSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- January 2013
Registered with the Care Quality Commission on 7 January 2013.
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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