CQC report explained · a residential care home
What the CQC found at Ash Villa
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, December 2020
Ash Villa was inspected but not rated; inspectors were assured about most infection controls, but some individual risk planning was incomplete.
This was an announced, targeted inspection on 18 November 2020. It looked at infection prevention and control during the coronavirus outbreak, rather than carrying out a full inspection of the home.
Inspectors were assured about visitor procedures, social distancing, personal protective equipment, testing, cleaning and arrangements for people who tested positive. The home also supported people to keep in touch with relatives when visiting was restricted.
There were some shortfalls. Risk assessments for people in high-risk groups were generic rather than personalised, and new cleaning arrangements had not reached all cleaning staff. The area for putting on and removing protective equipment was changed during the inspection.
The home was inspected but not rated. This means the report does not give an overall rating or ratings for the five key questions.
Visitor infection controls
The home had procedures for visitors, including relatives and healthcare professionals, to reduce the spread of infection.
“There were procedures in place for visitors to the service, including healthcare professionals and relatives to reduce and prevent the spread of infection.” from the report
Testing and protective equipment
There was a regular testing programme, and staff had suitable protective equipment in good supply.
“There was a clear regular programme for staff and people living in the home to be tested for COVID-19.” from the report
Plans for outbreaks
The home had a contingency plan for positive tests and staff shortages, including arrangements to reduce cross-infection.
“A robust contingency plan was in place and used for when positive testing or isolation for staff or people arose.” from the report
Contact with relatives
When visits were restricted, staff helped people keep in touch with relatives by telephone and letters.
“The provider ensured people maintained contact with relatives by staff supporting them with telephone calls and letter writing.” from the report
Risk assessments were not personalised
needs fixingRisk assessments for people in high-risk groups were generic and did not identify each person's individual risks.
“A generic risk assessment was in place for people in high risk groups, but not individualised to identify personal risks.” from the report
Cleaning instructions had not reached everyone
needs fixingNew ways of working had not been passed on to all cleaning staff. The deputy manager was addressing this.
“The deputy manager had identified that the new ways of working had not been filtered down to all cleaning staff and was addressing this.” from the report
- 01How are infection-related risks assessed and recorded for each person, rather than using only a generic assessment?
- 02How do you check that all cleaning staff understand and follow the current cleaning arrangements?
- 03What arrangements are now in place for visits from relatives and healthcare professionals?
- 04How often are staff and residents tested, and what happens if someone tests positive?
- 05How do you make sure the area for putting on and removing protective equipment remains suitable?
This was a targeted inspection of infection prevention and control during a coronavirus outbreak; the service was inspected but not rated and the other key questions were not assessed. This explanation was written from the published report of 11 December 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.
What inspectors found, February 2020
Rated Good; inspectors found safe, kind and personalised care, with the rating unchanged since 2017.
This was an unannounced inspection on 17 December 2019. One inspector spoke with people living at the home, a relative and staff. They also observed care and checked care plans, medicines records, staff records and management audits.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, well-managed medicines, detailed care plans, kind relationships and support that respected people's choices and independence.
The home was larger than current best practice guidance suggests, but inspectors said it gave people plenty of space. The previous inspection rating was also Good, published on 7 July 2017.
Safe staffing and medicines
Inspectors found enough staff to meet people's needs, including when people went out. Medicines were organised and given safely.
“There were enough staff to ensure that people's needs were met safely.” from the report
Kind, respectful care
Staff treated people with warmth and respect. People were supported to make choices and to do things for themselves.
“People had caring, kind supportive relationships with the staff who supported them.” from the report
Personalised support
Care plans gave staff detailed information about people's health, preferences and communication. Staff who knew people well helped provide consistent care.
“Care plans were personalised and very detailed.” from the report
Meaningful activities
People took part in activities they chose, including day services, social groups, holidays and activities at home.
“People led active lives full of social activities.” from the report
Good leadership and oversight
The home had an open culture. Leaders used audits, reviews and daily wellbeing information to monitor safety and quality.
“Regular reviews and audits were completed to ensure the service was meeting standards and continually improving.” from the report
Property larger than current guidance
minorThe home was larger than current best practice guidance for this type of service. Inspectors also noted that its size gave people additional living space.
“The service was a larger property than current best practice guidance.” from the report
- 01How would you support my relative's specific health conditions, dietary needs and communication style?
- 02How do you make sure medicines, including medicines taken when needed, are given safely?
- 03How would you involve my relative in decisions if they cannot communicate verbally?
- 04What activities and outings could my relative choose, and how would staffing support those choices?
- 05How would you support my relative's end of life wishes if their needs changed?
This was an unannounced inspection covering all five CQC questions, including the premises and care provided; all five ratings remained Good from the previous inspection. This explanation was written from the published report of 5 February 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 Villa
3 rated inspections over 5 years: the service has held its Good rating throughout.
- December 2020Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- February 2020Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 13 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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