CQC report explained · a residential care home
What the CQC found at Ashbourne House Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, safe recruitment, appropriate risk assessments and generally correct medicines management. They noted a shower room that was difficult to clean and a small number of medicine records needing better sign-off.
- Effective?
- Requires improvement
- This area was not assessed during this focused inspection. Its previous rating was carried forward.
- Caring?
- Good
- This area was not assessed during this focused inspection. Its previous rating was carried forward.
- Responsive?
- Requires improvement
- This area was not assessed during this focused inspection. Its previous rating was carried forward.
- Well-led?
- Good
- Inspectors found better quality checks, improved oversight and positive relationships between managers and staff. Relatives were happy with communication and the opportunity to give feedback.
What inspectors found, November 2021
Rated Good; inspectors found safe care and improved management, but a shower room needed refurbishment and some medicine records were incomplete.
This was an unannounced focused inspection on 25 October and 1 November 2021. Inspectors reviewed care, medicine, recruitment and management records. They spoke with staff, one person living at the home and ten relatives.
The home was rated Good overall. Safe and Well-led were both rated Good. Inspectors found enough staff, safe recruitment, correctly managed medicines overall and improved quality checks. Relatives said people were safe and spoke positively about the staff and management.
There were some remaining issues. A downstairs shower room had flooring and fittings that were difficult to clean, and a small number of medicine records had handwritten information that was not signed. The provider agreed to refurbish the room within two weeks, and the manager said staff would be reminded about medicine recording procedures.
The previous rating was Requires Improvement, published in June 2021. The provider had completed an action plan, and inspectors found the home was no longer breaching regulations. This inspection only assessed Safe and Well-led, while the other ratings were carried forward from the earlier inspection.
Enough suitable staff
Inspectors found enough staff to meet people's needs. Recruitment checks included checks with the Disclosure and Barring Service.
“There were enough staff to meet people's needs and support them appropriately.” from the report
Improved management checks
The home had introduced regular audits and an additional monthly report to directors. Inspectors found the service was no longer in breach of the governance regulation.
“The registered manager used a range of audits to assess and monitor the quality of the service, including checks on medicines management, health and safety and care plans.” from the report
Positive staff and relative feedback
Relatives spoke positively about the care, staff and management. Staff said morale and teamwork had improved.
“Staff felt there had been an improvement in team working and morale and were complimentary about changes introduced by the new registered manager.” from the report
Regular family contact
The home had recently introduced monthly contact with relatives to share information and gather feedback.
“Regular monthly contact with relatives had recently been introduced to ensure information was shared and to provide an opportunity for feedback.” from the report
Shower room condition
needs fixingThe downstairs toilet and shower room had flooring and pipework that were difficult to clean. The provider agreed to replace the flooring, toilet and sink, and CQC said it would check this.
“Flooring in the downstairs toilet/shower room looked dirty and was not adequately sealed.” from the report
Medicine record sign-off
minorMost medicine administration records were completed correctly, but a small number had handwritten information without the required signatures or countersignatures.
“However, a small number had additional handwritten information which had not been signed or countersigned by staff to ensure it was correct.” from the report
PPE practice
minorInspectors were only somewhat assured that personal protective equipment was being used effectively and safely. They also reminded staff to follow current mask-wearing guidance.
“We were somewhat assured that the provider was using PPE effectively and safely.” from the report
- 01Has the downstairs toilet and shower room now been refurbished, including its flooring, toilet and sink?
- 02What checks are now in place to make sure all medicine record amendments are signed or countersigned?
- 03What changes have been made to ensure staff use PPE and masks correctly?
- 04How often are relatives contacted now, and how are their concerns and feedback recorded?
- 05What were the ratings and findings for Effective, Caring and Responsive at the previous comprehensive inspection?
This was a focused inspection of Safe and Well-led, including infection control; the other ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 20 November 2021 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, June 2021
Ashbourne House Care Home rated Requires Improvement; inspectors found staffing and safeguarding were good, but medicines records and management checks were not reliable.
This was a focused inspection on 15 and 28 April 2021. Inspectors looked only at Safe and Well-led because the inspection followed concerns about medicines and management. They spoke with people, relatives and staff, and reviewed care, medicines, staff and management records.
The home had enough staff. Recruitment checks and training were in place. People were protected from abuse and harm, and infection control arrangements were mostly satisfactory. Some building improvements had also been made.
However, medicines records were incomplete. Body maps for prescribed creams were missing important details, and opening dates for creams were not recorded. Systems for checking quality had not found or fixed these problems quickly enough. Relatives also gave negative feedback about being kept informed.
The overall rating remained Requires Improvement, as did Safe and Well-led. The home was already rated Requires Improvement at the previous inspection, and the report says enough improvement had not been sustained.
Staffing and training
Inspectors found enough staff to support people. Recruitment checks, induction and mandatory training were in place.
“There were enough staff to support people. During the inspection we observed appropriate levels of staffing to support the people who used the service.” from the report
Safeguarding
People were protected from abuse and harm. People and relatives said they felt safe with the staff.
“People were protected from the risks of abuse and harm and people said they trusted staff to keep them safe.” from the report
Infection control
Inspectors were assured about PPE, testing, visiting arrangements and the home's ability to prevent or manage infection outbreaks.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Building improvements
The provider had started a premises improvement plan and was updating the building and redecorating bedrooms and communal areas.
“The provider had implemented a premises improvement plan and was on track with updating the building and redecorating bedrooms and communal areas.” from the report
Incomplete medicines records
seriousRecords for prescribed creams were missing people's names, cream names and opening dates. The report says this placed people at risk of harm, although no evidence of harm was found.
“Body maps had information missing, such as the person's name and the name of the cream. Prescribed creams did not have opening dates documented.” from the report
Weak management checks
seriousAudits did not reliably identify problems or make sure they were fixed. This was part of the continuing breach of Regulation 17.
“The service had poor audit trails and audit systems were not robust. Governance systems failed to identify some of the issues we found during the inspection.” from the report
Relatives not always kept informed
needs fixingSome relatives said the home did not contact them regularly with updates. The manager said this would be followed up through the relatives' survey.
“We received negative feedback from relatives about the service keeping relatives informed.” from the report
High-touch cleaning checks
minorCleaning had increased and some checklists were used, but there was no specific checklist for high-touch surfaces.
“Cleaning regimes had increased and some checklists were used, however, a specific checklist for high touch surfaces was not in place.” from the report
- 01How are prescribed creams now recorded, including the person's name, the cream name, where it should be applied and the opening date?
- 02How have you improved audits so that medicines and fire safety issues are identified and fixed promptly?
- 03How do you now keep relatives informed about their family member's care and changes in their condition?
- 04What progress has been made with the premises improvement plan since this inspection?
- 05What action has been taken following the Regulation 17 breach and the CQC action plan?
This was a focused inspection of Safe and Well-led only; the other ratings were carried over from previous comprehensive inspections. This explanation was written from the published report of 16 June 2021 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 House Care Home
4 rated inspections over 5 years: the service has held its Good rating throughout.
- November 2021Goodcurrent ratingup from Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Good
- June 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- October 2019Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- January 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2014
Report published without a new overall rating.
- February 2014
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 28 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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