CQC report explained · a nursing home
What the CQC found at Ash Hall Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, May 2022
Rated Requires Improvement; inspectors found some safety risks and weak monitoring, although care, medicines and infection control had strengths.
This was an unannounced focused inspection on 14 and 16 February 2022. Inspectors reviewed records, medicines, staff recruitment, building safety and infection control. They spoke with people, relatives, staff and managers.
The home had enough staff when inspectors visited. Medicines were safely managed and infection control arrangements were satisfactory. People said they felt safe, were involved in their care and could raise concerns.
However, not all windows had suitable restrictors and some radiators were not covered or safely monitored. This created risks of falls, scalds and burns. One staff recruitment concern had not been risk assessed until inspectors raised it.
The overall rating remains Requires Improvement. This was the third consecutive inspection with that rating. The home was also rated Requires Improvement for Safe and Well-led. The other three areas were not inspected and kept their previous ratings.
Medicines
Medicines were stored, given and recorded safely by trained staff. Staff knew people well enough to recognise when some as-needed medicines were needed.
“Medicines were safely stored, administered and recorded by trained staff.” from the report
Infection control
Inspectors were assured that the home used protective equipment properly, supported testing and had arrangements to prevent or manage outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
People felt involved
People were involved in their care and felt able to say if they were unhappy. Relatives said they could approach the management team with concerns.
“People were included in their care which led to them being empowered.” from the report
Staffing levels
There were enough staff to support people safely during the inspection. Recruitment was continuing to increase staffing levels.
“There were enough staff available to support people.” from the report
Care records
Care records were current and accurate, and staff understood how to support people safely.
“People's care records were up-to-date, accurate and staff knew how to support people safely.” from the report
Window safety
seriousNot all windows had compliant restrictors. This left people at risk of falling from height. The provider said most windows had since been fitted correctly, but not all were compliant.
“This meant people were at risk of falling from height.” from the report
Radiator safety
seriousSome radiators were not covered and temperature checks were not put in place promptly. This left people at continued risk of scalding or burns until checks were introduced.
“Radiators were not covered to protect people from scalding.” from the report
Governance and lasting improvement
needs fixingThe home's monitoring systems did not identify important building risks. This was the third consecutive Requires Improvement rating, so the provider had not demonstrated sustainable improvement.
“This is the third consecutive time the provider has been rated requires improvement, and therefore have not been able to demonstrate their ability to implement and sustain effective improvements at the service.” from the report
Recruitment checks
seriousA concern was found in one staff member's recruitment information, and there was no risk assessment until inspectors raised it.
“DBS checks had been completed for staff; however, we found a concern in relation to one staff member and there was no risk assessment in place.” from the report
Training updates
minorSome staff training was not updated promptly, and some mandatory training needed refreshing. Management acted after inspectors raised this.
“Staff training was not always up-dated in a timely manner and this was being addressed by management.” from the report
- 01Have all windows now got compliant restrictors, and how do you check any windows that cannot have them fitted?
- 02How are radiator temperatures checked and recorded, and what protection is provided against scalds and burns?
- 03What has changed since the inspection to make sure building safety risks are found promptly?
- 04How do you complete and record recruitment risk assessments before staff start working with residents?
- 05How will you show that improvements are being maintained after the action plan is completed?
This was a focused inspection of Safe and Well-led only, prompted by concerns about staffing and infection control; the other ratings carried over from the previous inspection. This explanation was written from the published report of 11 May 2022 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, September 2019
Rated Requires Improvement; inspectors found kind and effective care, but medicines records, care records and management checks were not always reliable.
Inspectors visited without notice on 29 and 30 August 2019. They spoke with people, relatives, staff and managers. They observed care and checked care records, medicines, recruitment files and management checks.
The home was rated Good for Effective, Caring and Responsive. People were treated kindly, supported to make choices, helped with food and health needs, and offered activities and personalised care.
The home was rated Requires Improvement for Safe and Well-led. Medicine records were not always complete, some care records did not reflect changing needs, and important audits had fallen behind. The overall rating remained Requires Improvement, as it had been at the previous inspection.
Kind and respectful care
People and relatives described staff as caring. Inspectors saw staff supporting people patiently, respectfully and in a way that promoted dignity and independence.
“We observed caring interactions between people and staff.” from the report
Trained staff and timely support
People received support promptly, call bells were answered quickly and recruitment checks were completed. Staff had induction, ongoing training and training for specific conditions.
“People were supported by safely recruited staff who had the skills and knowledge to provide safe and effective support.” from the report
Food, fluids and health support
People spoke positively about the food. Nutritional risks, weight and fluid intake were monitored, and staff worked with health professionals when needed.
“People's nutritional risks were managed and monitored.” from the report
Personalised activities and communication
Staff understood people's communication needs and preferences. People took part in activities such as music, games and reminiscence sessions, while being free to choose whether to join in.
“People received personalised care because staff knew people well and understood their preferences in how they wished their care to be provided.” from the report
Open management response
The management team accepted feedback and had begun an action plan. They agreed to provide CQC with regular updates about progress.
“The registered manager and provider were open and responsive to our feedback.” from the report
Medicine recording
seriousRecords did not always show the correct amount of medicines held, and topical medicines were not consistently recorded. Daily checks identified before the inspection had not yet started.
“Some improvements were needed to ensure medicine recording was consistently completed by staff.” from the report
Management checks fell behind
needs fixingMedicine, care plan and oral care audits had not been completed for two months. A shortage of nurses had affected managers' ability to carry out monitoring.
“Some audits had not been completed for two months, such as medicine audits, care plan audits and oral care audits.” from the report
Environment still being improved
minorChanges such as dementia-friendly signs, new flooring and new bathrooms had started but were not finished. The home was still working through its improvement plan.
“This was an ongoing process and there was a plan in place to ensure the service met people's needs.” from the report
- 01How are medicines and topical creams now recorded, checked and audited?
- 02How will you make sure care plans are updated when people's needs or preferences change?
- 03Have the medicine, care plan and oral care audits been brought up to date?
- 04How has the shortage of nurses been resolved, and how does it affect managers' monitoring duties?
- 05Which environmental improvements have been completed since this inspection?
This was an inspection of all five CQC questions, covering the care provided, the premises, medicines, staffing, records and how the home was managed. This explanation was written from the published report of 24 September 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 Hall Nursing Home
5 rated inspections over 5 years: the service has held its Requires improvement rating throughout.
- May 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2019Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- September 2018Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2018Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- January 2017Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- May 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- December 2011
Registered with the Care Quality Commission on 23 December 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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