CQC report explained · a residential care home
What the CQC found at Ash House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found risks were assessed, medicines were managed safely and there were enough staff to support people. They noted that face masks were not worn at all times and that personal evacuation plans needed review for reduced night staffing.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward when calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward when calculating the overall rating.
- Well-led?
- Good
- Inspectors found better audits, clearer oversight and a more positive and inclusive culture. The manager was described as visible, supportive and responsive to feedback.
What inspectors found, November 2022
Rated Good; inspectors found safer care and better management, but infection control and night-time evacuation plans still needed attention.
This was an unannounced focused inspection. Inspectors looked at Safe and Well-led because concerns had been raised about recruitment. They met all six people living at the home, spoke with relatives and staff, observed care, and checked care, recruitment and management records.
The home was rated Good for Safe and Well-led. Inspectors found people were supported by staff who knew them well, had enough staff for activities and visits, and received safe support with medicines and risks. The home was clean and well maintained overall, although some dust in bathroom extractor fans was found and cleaned straight away.
The service had improved since the previous inspection, when it was rated Requires Improvement and breached regulations about risk assessment and quality monitoring. At this inspection, those breaches had been addressed and the provider was no longer in breach.
The other three key questions were not inspected during this visit. Their previous ratings were used to calculate the overall rating, so this report does not give a new view of Effective, Caring or Responsive care.
Person-centred support
Staff focused on people's abilities and interests. People were supported to take part in activities, household tasks and learning new skills.
“Staff focused on people's strengths and promoted what they could do, so people had a fulfilling and meaningful everyday life.” from the report
Enough staff
There were enough staff to provide one-to-one and two-to-one support, including for activities and visits.
“The service had enough staff, including for one-to-one and two-to-one support for people to take part in activities and visits how and when they wanted.” from the report
Safe medicines support
Medicines were stored within a safe temperature range. Staff had training and competency checks, and records showed medicines were given as prescribed.
“Electronic records supported people had received their medicines as prescribed.” from the report
Improved management
Managers carried out audits, recorded actions and monitored progress. Inspectors found the home had improved its oversight since the previous inspection.
“At this inspection we found improvements had been made.” from the report
Positive relationships
People appeared comfortable with staff, and relatives said staff knew people's needs and risks well.
“Observations of people with staff indicated they appeared comfortable and had positive working relationships with the staff.” from the report
Face-mask use
needs fixingStaff did not wear face masks at all times because of the effect on communication. The report says this reduced the home's ability to prevent infection outbreaks effectively.
“As staff did not wear face masks at all times this reduced their ability to effectively prevent infection outbreaks.” from the report
Night-time evacuation plans
needs fixingThe manager agreed to review personal evacuation plans so they reflected the lower staffing level during the night.
“Following discussions, during the inspection the register manager agreed to review people's personal evacuation plans to ensure these took account of the reduced staffing levels through the night.” from the report
Recruitment information
minorInspectors discussed obtaining additional information for recruiting staff from overseas. The manager agreed to put this in place.
“We discussed with the registered manager additional information that could be obtained to support the recruitment of staff from overseas.” from the report
- 01How have you updated each person's personal evacuation plan to reflect staffing levels during the night?
- 02When are staff required to wear face masks, and what would happen if there were an infection outbreak?
- 03What additional checks or information are now collected when recruiting staff from overseas?
- 04What changes have been made since the previous Requires Improvement inspection, and how do you check that they remain effective?
- 05How will you involve relatives in care reviews, feedback and decisions about future support?
This was a focused inspection of Safe and Well-led only; the other three key-question ratings were carried forward from the previous inspection. This explanation was written from the published report of 2 November 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, March 2020
Rated Requires Improvement; inspectors found kind, person-centred care but serious safety and quality-checking problems.
Inspectors visited without warning on 4 February 2020. They met all six people, spoke with relatives, staff, managers and an external professional, and checked care records, medicines, recruitment records and the home.
The home was rated Good for Effective, Caring and Responsive care. People were supported to make choices, stay healthy, keep in touch with relatives, build independence and take part in activities they enjoyed.
The home was rated Requires Improvement for Safe and Well-led care. Inspectors found expired fire extinguishers, faulty fire doors, burn risks, uneven surfaces, poor cleanliness and medicines stored above the manufacturer's recommended temperature.
The overall rating means the home was not consistently meeting the expected standard. The provider breached Regulations 12 and 17 and was asked to provide an action plan. CQC said it would monitor progress and return for another inspection.
Kind and respectful support
Inspectors saw positive interactions. Staff listened to people, respected their preferences and supported their dignity and independence.
“People were spoken with kindly and respectfully by staff and were listened to.” from the report
Personalised care
Care plans recorded individual likes, dislikes, communication methods and needs. Staff followed these plans in daily care.
“People using the service received planned and coordinated person-centred support that was appropriate and inclusive for them.” from the report
Choice and independence
People were encouraged to make decisions, choose food and drinks, develop skills and take part in everyday tasks.
“People were supported to have maximum choice and control of their lives.” from the report
Family and community links
People were supported to visit relatives, use local facilities and take part in trips and activities suited to their interests.
“People were supported to maintain relationships, follow their interests and take part in activities to meet their specific preferences.” from the report
Unmanaged premises risks
seriousSome fire extinguishers had expired and some bedroom fire doors did not close properly. There were also unguarded radiators, a very hot towel rail and an uneven driveway, creating possible injury risks.
“This meant that there were on-going risks to people's safety.” from the report
Medicines stored too warmly
seriousSome medicines were kept above the manufacturer's temperature guidance for more than a month. The recorded corrective action had not been carried out.
“There is a risk that some medicines could be affected and may not work correctly if stored at a higher temperature than the manufacturer's guidance.” from the report
Infection-control problems
needs fixingInspectors found mould on a shower chair, dust in a ventilation system, damaged bathroom wood and a strong odour in one bedroom. Cleaning checks had not always been effective.
“We saw that the material back of a shower chair was dirty and had mould growth.” from the report
Weak quality monitoring
seriousAudits did not identify several safety, infection-control, food-hygiene and fluid-monitoring problems. Issues identified by an external health and safety audit had not been corrected quickly enough.
“The provider's systems in place to review quality were not always effective.” from the report
Fluid monitoring
needs fixingRecords showed that one person's fluid intake was below the planned amount on two of three days. The manager had not identified this through monitoring.
“The registered manager's monitoring to ensure people were offered sufficient fluid to stay healthy was ineffective.” from the report
- 01Have the expired water fire extinguishers been replaced, and are all bedroom fire doors now closing correctly?
- 02Where are medicines stored now, and how do you check that their temperature stays within the manufacturer's guidance?
- 03What has been done to remove the mould, dust and water damage identified during the inspection?
- 04How do you now check fluid-intake records and act when a person's intake is below their care-plan target?
- 05What new quality audits are in place, and can you show how they have identified and fixed risks since the inspection?
This was an unannounced inspection of the care, premises and management of the home, covering all five CQC questions; the visit took place on 4 February 2020. This explanation was written from the published report of 27 March 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 Ash House
4 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- November 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2020Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- August 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2015
Registered with the Care Quality Commission on 12 March 2015.
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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