CQC report explained · a nursing home
What the CQC found at Ashbrook Court Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were assessed and managed, medicines were given safely, infection controls were in place and staff understood safeguarding procedures. Staffing comments were mixed, but inspectors found enough competent staff on duty during the visit.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its rating carried over from the previous inspection.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its rating carried over from the previous inspection.
- Responsive?
- Requires improvement
- This key question was not inspected during this focused visit. Its rating carried over from the previous inspection.
- Well-led?
- Good
- Inspectors found positive leadership, person-centred care and suitable systems for checking quality, reviewing incidents and making improvements.
What inspectors found, June 2023
Ashbrook Court Care Home is rated Good overall; inspectors found safe, well-managed care, with staffing experiences varying between residents.
This was an unannounced, focused inspection on 17, 18 and 21 April 2023. Inspectors checked Safe and Well-led. They spoke with people, relatives and staff, observed care, and reviewed care records, medicines, recruitment and quality checks.
The home was rated Good for Safe and Well-led. Inspectors found suitable arrangements to manage risks, safeguard people, give medicines, prevent infection and learn from incidents. They found enough competent staff on duty during the inspection, although people's views about staffing levels were mixed.
The overall rating changed from Requires Improvement to Good. The previous inspection was published in October 2019. Inspectors said improvements had been made and the home was no longer in breach of Regulation 12.
Safe medicines
Medicines records were accurate and people received their medicines as prescribed. Staff who administered medicines were trained and checked as competent.
“Accurate medicines records were maintained, and people received their medicines as prescribed.” from the report
Risk management
Risks to people's safety and wellbeing were recorded, with actions to reduce them. Fire safety arrangements and emergency plans were also in place.
“Risks to people's safety and wellbeing were assessed and recorded.” from the report
Infection control
Inspectors were assured that infection risks were managed, including the safe use of protective equipment and the prevention of outbreaks.
“We were assured the provider was using Personal Protective Equipment [PPE] effectively and safely.” from the report
Learning and improvement
The home reviewed safeguarding concerns, complaints, accidents and incidents to identify lessons and possible trends.
“Effective arrangements were in place to learn when things went wrong.” from the report
Management and quality checks
Inspectors found a positive culture and regular checks of important information, including falls, infections, pressure ulcers and weight changes.
“The quality assurance arrangements monitored the experience of people being supported through its internal auditing processes.” from the report
Mixed views about staffing
minorSome people said they sometimes waited for help or were left alone. Inspectors found staffing was appropriate on the inspection days, but families should ask how staffing levels are maintained at different times.
“Comments from people using the service and those acting on their behalf were variable relating to staffing levels.” from the report
- 01How quickly are call bells usually answered, particularly at night and during busy periods?
- 02How do you check that staffing levels remain enough to meet people's needs on every shift?
- 03What changes were made after the previous breach of Regulation 12, and how do you check that those changes are still working?
- 04How are medicines records checked to make sure people continue to receive medicines as prescribed?
- 05How will you keep families informed about incidents, complaints and improvements?
This was a focused inspection of Safe and Well-led only; the other key question ratings carried over from the previous inspection. This explanation was written from the published report of 10 June 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, February 2022
Ashbrook Court Care Home: inspected but not rated; inspectors found good infection control and visiting arrangements, but some COVID-19 risk assessments and audit records needed improvement.
This was an unannounced, targeted inspection on infection prevention and control during the COVID-19 pandemic. Inspectors also asked about staffing pressures and whether these affected care.
The home had arrangements for safe visits, visitor screening, testing, personal protective equipment and cleaning. Relatives said they were kept informed and described the home as clean.
Staffing pressures linked to COVID-19 were managed with extra shifts and agency staff where needed. Inspectors found this had not affected care. However, the home had not assessed some pandemic risks for people and staff, and records did not show when actions from infection control audits had been completed.
The overall service was inspected but not rated. The Safe key question was also inspected but not rated, so this report does not give a new overall quality rating.
Family communication
Relatives said they were kept informed about visiting arrangements throughout the pandemic. The home also used calls, window visits and video calls to help families stay in contact.
“We have been informed by newsletter and emails.” from the report
Infection control
Inspectors saw staff using masks, gloves and aprons correctly, with good hygiene practices. The home had visitor screening, testing and safe admission arrangements.
“Appropriate infection prevention control practices were observed for staff, such as the wearing of masks, gloves, aprons and included good hygiene practices.” from the report
Clean environment
Cleaning schedules were being followed. The home was visibly clean and free from unpleasant smells.
“The environment was visibly clean and odour free.” from the report
Managing staff pressures
The home used agency staff and extra shifts when needed during the outbreak. Inspectors found this had not affected care.
“This did not impact on service delivery or the quality of care provided.” from the report
Individual COVID-19 risk assessments
needs fixingThe home had not identified current and emerging pandemic risks for some people and staff, including people with underlying health conditions and some ethnic minority staff groups.
“current and emerging risks presented by the pandemic had not been identified for people or staff” from the report
Recording audit actions
needs fixingInfection control audits were completed, but records did not show when identified actions had been completed. Inspectors said this approach needed reviewing.
“information to demonstrate when actions highlighted had been completed were not recorded and required reviewing.” from the report
- 01How do you now identify and record COVID-19 risks for residents with underlying health conditions?
- 02How do you assess infection risks for staff who may be at increased risk?
- 03How do you record that actions from infection prevention and control audits have been completed?
- 04What infection prevention training have staff completed, including training on using personal protective equipment?
- 05How are visits arranged and what screening and testing is required for visitors?
This was an unannounced targeted inspection of infection prevention and control and COVID-19 staffing pressures; only Safe was inspected and it was not rated. This explanation was written from the published report of 24 February 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 Ashbrook Court Care Home
7 rated inspections over 8 years: the service has improved, from Requires improvement to Good.
- June 2023Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- February 2022Inspected but not ratedSafe: Inspected but not rated
- November 2019Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- March 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- October 2017Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- April 2017Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- August 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- September 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2015
Report published without a new overall rating.
- October 2014
Report published without a new overall rating.
- August 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- October 2011
Registered with the Care Quality Commission on 10 October 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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