CQC report explained · a residential care home
What the CQC found at Ashbourne Court Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some medicines were not managed safely or recorded correctly. Accident and incident records did not always show that causes had been analysed or that steps had been taken to prevent a repeat, although staffing, risk assessments, safety checks and infection control were found to be satisfactory.
- Effective?
- Good
- This question was not inspected during this focused inspection. Its previous rating was used in calculating the overall rating.
- Caring?
- Good
- This question was not inspected during this focused inspection. People and relatives nevertheless gave positive feedback about the care, and inspectors saw staff being kind and friendly.
- Responsive?
- Good
- This question was not inspected during this focused inspection. The previous rating was used in calculating the overall rating.
- Well-led?
- Requires improvement
- The home's monitoring systems had not identified the medicines and accident-record problems. Staff meetings had also not always been regular, although the culture was positive and the provider took action after the inspection.
What inspectors found, July 2023
Rated Requires Improvement; inspectors found kind, timely care but unsafe medicines records and weak checks on accidents.
This was an unannounced focused inspection on 28 June 2023. One inspector spoke with people, staff, relatives and professionals, and checked care records, medicines, staff files, rotas, accidents and management records.
The home had enough staff and people received timely support. Inspectors saw kind and friendly care, a calm atmosphere, suitable risk assessments and regular safety checks. People and relatives said they were happy with the care.
However, some medicines were not managed according to the home's procedures. Records did not always show clearly what had been given. Accident records were sometimes incomplete and did not show that lessons had been learned.
The overall rating changed from Good to Requires Improvement. Safe and Well-led were both rated Requires Improvement. The other three questions were not inspected, and their previous ratings were used when calculating the overall rating.
Enough staff
The home had enough staff on duty to meet people's needs. People did not have to wait long for support.
“We looked at the staff rotas for the last 6 weeks and found that there was always enough staff on duty to meet the needs of people who used the service.” from the report
Kind and calm care
Inspectors saw kind and friendly staff and a calm atmosphere. People and relatives generally said they were happy with the care.
“From our observations, we found people did not have to wait long when they requested support. The staff did not appear rushed and there was a calm and efficient atmosphere.” from the report
Risk and building safety
Risk assessments were detailed and regularly reviewed. The home also carried out checks on fire safety, utilities and the environment.
“Risk assessments were detailed and included measures already in place to manage the risk, and further actions needed should the risk occur.” from the report
Positive relationships
People, relatives, staff and visiting professionals described the home as caring, open and supportive.
“There was a positive culture at the service and the atmosphere was relaxed. People and relatives told us they were happy and the care and support was good.” from the report
Activities and visitors
People had access to a range of activities. Relatives said they felt welcome and people could receive visitors when they wished.
“A part-time activities coordinator provided people with a range of activities and people spoke highly of them.” from the report
Medicines were not always managed safely
seriousStaff did not always follow the home's medicines procedures. There were missing tablets, incorrect records and a missing medicines administration record, creating a risk that people would not receive medicines as prescribed.
“People's medicines were not always managed in line with the provider's policy and procedure. This meant there was an increased risk that people would not receive their medicines safely and as prescribed.” from the report
Accident records did not show learning
needs fixingSome accident and incident records were incomplete. They did not always explain what had happened or how the home would reduce the risk of it happening again.
“There was not always evidence that circumstances leading to the accident or incident were analysed, discussed and systems put in place to prevent re-occurrence.” from the report
Quality checks missed problems
needs fixingThe home's audits did not identify the medicines and accident-record issues found by inspectors. The provider said monitoring would become more detailed and frequent.
“The provider's systems for monitoring the quality and safety of the service had not always been effective.” from the report
Team meetings were irregular
minorStaff meetings had not always taken place regularly. The manager accepted that meetings needed to be more frequent.
“There were staff meetings organised so staff could discuss any areas of concerns or share information but these had not always been regular.” from the report
- 01What changes have been made to medicines administration, recording and auditing since the inspection?
- 02How do you now check that staff follow the medicines policy, including when tablets are dropped or left with a person?
- 03How are accidents and incidents analysed, and how do you make sure lessons are recorded and acted on?
- 04How often are quality and safety audits now completed, and who checks that actions are finished?
- 05When are staff meetings held, and how are concerns and important care information shared between shifts?
This was an unannounced focused inspection of Safe and Well-led only; the other ratings were carried over from the previous inspection and used to calculate the overall rating. This explanation was written from the published report of 22 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, August 2019
Rated Good; inspectors found kind, safe and personalised care, but staffing levels had not always been consistent.
This was an unannounced inspection on 14 June 2019. Two inspectors spoke with people living in the home, relatives, staff and visiting professionals. They observed care and checked care plans, medicines records, staff files, risk assessments and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that people were protected from avoidable harm, received their medicines correctly, had access to health professionals and were supported with food and drink.
People were treated with kindness and respect. Staff knew people's histories and preferences, supported their independence and offered activities and time together. The home had a friendly atmosphere and relatives and staff were involved in decisions about the service.
Inspectors noted that staffing levels had varied during the previous year. The manager said this had been addressed through recruitment and regular agency cover. Inspectors recommended continued monitoring to make sure enough staff were consistently available.
Safe medicines
Medicines records were fully completed. Staff were trained and checked as competent, and medicines were securely stored and regularly audited.
“Each person had a medicines administration record in place which was fully completed.” from the report
Kind and respectful care
Inspectors saw staff approach people calmly and provide reassurance. People were treated with dignity and their privacy was respected.
“We observed staff treat people with kindness.” from the report
Personalised support
Care plans included people's needs, life histories and preferences. Staff could describe what people enjoyed and how they communicated.
“Each person had a detailed care plan in place which reflected their needs and how they preferred their care to be provided.” from the report
Activities and relationships
People could take part in a range of activities, receive individual time in their rooms and use technology to keep in touch with relatives.
“A range of activities was available to people such as poetry reading, arts and crafts, quizzes, exercises, music groups and visiting entertainers.” from the report
Active management
The manager worked alongside staff and used audits, surveys and meetings to monitor the home and involve people, relatives and staff.
“Audits were completed on a regular basis to monitor the care provided to people.” from the report
Staffing was not always consistent
needs fixingRotas showed that the same staffing levels had not always been in place during the previous year. Some relatives, staff and professionals were unsure whether there were always enough staff, so inspectors made a recommendation for ongoing monitoring.
“We recommend the provider ensures that sufficient staff are consistently deployed in order to provide people with safe, effective and responsive care.” from the report
More meaningful food choices may be needed
minorPeople were offered food choices, but inspectors said that visual choices might be more useful because most people living in the home had dementia.
“Due to the majority of people living with dementia a visual choice may be more meaningful to people.” from the report
- 01How do you check that staffing levels are sufficient on every shift, including when permanent staff are absent?
- 02What changes have been made since the inspection to monitor staff deployment?
- 03How do you offer visual food choices to people who may find written choices difficult to understand?
- 04How are activities matched to each person's life history, interests and communication needs?
- 05How will you involve our family member and us in reviewing their care plan?
This was an unannounced planned inspection covering all five CQC questions, including the care provided and the home environment. This explanation was written from the published report of 28 August 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 Ashbourne Court Care Home
5 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- July 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2019Goodstayed GoodSafe: GoodWell-led: Good
- October 2017Goodstayed GoodSafe: Good
- December 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- September 2014
Report published without a new overall rating.
- April 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 29 November 2010.
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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