CQC report explained · a nursing home
What the CQC found at Ash Lodge Care Home with Nursing
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Good
- Inspectors found robust risk assessments, enough staff and safe medicines procedures. Safeguarding systems, infection control and accident monitoring were also found to be in place.
- Effective?
- Requires improvement
- Staff sought consent and had relevant training, and people received support with food, drink and healthcare. However, some mental capacity and best interest records were incomplete, and one DoLS authorisation had expired while several renewals were late.
- Caring?
- Good
- People were treated with kindness, dignity and respect. Staff involved people in choices about daily care and respected their privacy.
- Responsive?
- Good
- Care plans were personalised and people had activities, communication support and help to maintain relationships. However, care plan reviews did not always involve people, relatives or representatives.
- Well-led?
- Requires improvement
- People, relatives and staff spoke positively about the management and staff felt supported. However, management systems did not consistently identify or correct missing mental capacity information or monitor DoLS renewals effectively.
What inspectors found, July 2023
Ash Lodge Care Home with Nursing was rated Requires Improvement; care was safe, kind and responsive, but mental capacity records and management checks were not reliable enough.
Inspectors carried out an unannounced comprehensive inspection over 9 and 10 May 2023. They spoke with people using the home, relatives, staff and a healthcare professional. They also reviewed care, medicines, recruitment and management records.
The home was rated Good for Safe, Caring and Responsive. Inspectors found enough staff, safe medicines practice, suitable risk assessments, kind care and support for people's communication, activities and relationships.
Effective and Well-led were rated Requires Improvement. Some DoLS renewals were not sent in time, and some mental capacity and best interest records were incomplete. Care plan reviews did not always involve people or their relatives.
The overall rating fell from Good at the previous inspection, published in February 2018. The CQC will ask for an action plan and continue to monitor the home.
Safe staffing and risk support
Inspectors found enough staff on duty and clear risk assessments to guide safe support. Recruitment checks had also been completed.
“Our observations during the day, indicated there were enough staff on duty to support people with their care needs.” from the report
Safe medicines
Medicines were given as prescribed, with trained staff, competency checks and accurate administration and stock records.
“People received their medicines safely and as prescribed and were supported by sufficient numbers of staff to ensure risk of harm was minimised.” from the report
Kind and respectful care
People were treated with kindness and respect. Staff involved people in everyday choices and protected their privacy and dignity.
“We observed kind and caring interactions between staff and people.” from the report
Personalised support and activities
Care plans recorded people's individual needs and preferences. People had opportunities for activities and were supported to maintain important relationships.
“People had opportunities to engage in meaningful activities.” from the report
Mental capacity and liberty safeguards
seriousThe home did not consistently follow the Mental Capacity Act. One DoLS authorisation had expired, several renewals were late, and some capacity and best interest records were missing important details.
“The provider was not consistently working in line with the principles of the MCA.” from the report
Incomplete care plan review involvement
needs fixingCare plan reviews did not always show involvement from people, relatives or representatives. Management said it would introduce a structured review programme.
“However, care plan reviews lacked involvement from people, their relatives and representatives.” from the report
- 01Have all missing capacity assessments and best interest decisions now been completed, signed and checked?
- 02How do you track DoLS expiry dates and make sure renewal requests are sent on time?
- 03How are residents, relatives or representatives now involved in care plan reviews?
- 04What changes have been made since the inspection to improve the systems that check care records and DoLS documentation?
- 05How will you show families that the improvements requested in the action plan have been completed?
This was an unannounced comprehensive inspection covering all five key questions, including infection prevention and control, the premises and the care provided. This explanation was written from the published report of 11 July 2023 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 2022
Inspected but not rated; inspectors were assured that infection control and visiting arrangements were being managed safely.
This was a targeted inspection about infection prevention and control during the COVID-19 pandemic. Inspectors also asked about staffing pressures and whether these affected people living at the home. The inspection was announced with 24 hours' notice.
Inspectors found good practice in visitor checks, infection control arrangements and the use of personal protective equipment. They were assured that the home was managing visiting, admissions, testing, shielding, social distancing and infection outbreaks in line with the guidance described in the report.
The home was inspected but not rated. This means the report does not give an overall quality rating or a rated score for Safe. The report says the service met the requirement for non-exempt staff and visiting professionals to be vaccinated against COVID-19.
Visitor infection checks
The home carried out comprehensive checks for visitors when they arrived, to help reduce the risk of infection.
“This included comprehensive checks for visitors on arrival.” from the report
PPE arrangements
Staff were following PPE guidance, and extra PPE was available near residents' rooms.
“Staff were adhering to Personal Protective Equipment (PPE) guidelines and extra PPE locations had been set up near to the resident's room.” from the report
Up-to-date infection policy
The infection control policy was current, and audits showed that actions had been taken to maintain standards.
“The infection control policy was up to date.” from the report
Inspectors raised no specific concerns in this report.
- 01How are you currently managing staffing pressures linked to COVID-19, and have they affected people's care?
- 02Do you still carry out the comprehensive visitor checks described in the report?
- 03Where is PPE kept near residents' rooms, and how do you check that staff use it correctly?
- 04How do you currently manage testing, admissions and possible infection outbreaks?
- 05How do you check that staff and visiting professionals meet the current COVID-19 vaccination requirements or have an exemption?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; the service was inspected but not rated and the other key questions were not assessed in this report. This explanation was written from the published report of 17 March 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.
Every inspection of Ash Lodge Care Home with Nursing
3 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- July 2023Requires improvementcurrent ratingSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Ash Lodge Care Home with Nursing →
- March 2022Inspected but not ratedSafe: Inspected but not rated
Read what inspectors found at Ash Lodge Care Home with Nursing →
- February 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 26 January 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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