CQC report explained · a nursing home
What the CQC found at Ashbrook Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Inspectors found systems to protect people, enough staff, safe medicine storage and good infection control. However, some risk assessments lacked personalised guidance, records were difficult to find, and one medicine administration was not recorded.
- Effective?
- Good
- People's health, nutrition and hydration needs were assessed and supported. Staff received training and worked with health professionals, although inspectors recommended improving the mealtime experience.
- Caring?
- Good
- People and relatives described staff as kind, caring and respectful. Inspectors saw patient interactions, people being treated with dignity, and support that reflected their histories, choices and beliefs.
- Responsive?
- Good
- Care plans were personalised and people were offered choices, activities and support to maintain relationships. The move from paper to electronic records meant some information was inconsistent or difficult to locate.
- Well-led?
- Good
- The home had a clear management structure, regular meetings and quality checks. Inspectors found a positive and open culture, but some problems were identified by inspectors rather than the home's own checks.
What inspectors found, September 2023
Rated Good overall, but Safe Requires Improvement because some risk guidance, records and medicine recording were not always reliable.
The inspection was unannounced and took place on 26 July 2023. Inspectors observed care, spoke with 15 people, four relatives and staff, and reviewed care plans, medicines records, recruitment, training, quality checks and infection control.
The home was rated Good overall. Effective, Caring, Responsive and Well-led were all rated Good. Inspectors found kind and respectful care, enough staff, suitable training, person-centred support, activities and a positive management culture.
Safe was rated Requires Improvement, as at the previous inspection. Some risk assessments did not give enough personalised guidance, some records were difficult to find during the move to electronic records, and one medicine administration had not been recorded correctly. The home took action after the inspection to address these issues.
Kind and respectful care
People and relatives were positive about staff. Inspectors saw warm interactions, patience and respect for people's privacy, dignity and choices.
“We observed staff engaging with people politely and patiently. There were warm and caring interactions between them.” from the report
Enough suitable staff
Inspectors found enough staff with the skills and experience to meet people's needs. Recruitment checks were completed appropriately.
“There were enough staff with the right skills and experience to meet the needs of people in the home.” from the report
Good health support
People's health, food and drink needs were monitored. Staff worked with doctors and other health professionals when support was needed.
“The staff and management team worked well with health professionals to ensure people were in the best of health.” from the report
Meaningful activities
People were offered regular activities and outings, including a seaside trip on the inspection day. Relatives and friends were able to visit.
“The schedule showed that there were 2 activities per day.” from the report
Positive management culture
People, relatives and staff could approach managers with concerns. The home used meetings, feedback and audits to support improvements.
“The provider had established a positive culture in the home.” from the report
Risk plans lacked detail
seriousTwo people at risk of epileptic seizures did not have enough personalised guidance about what staff should do during a seizure. The manager updated these plans after the inspection.
“There was a lack of detail in relation to what action staff should take should the person have a seizure.” from the report
Important records were hard to find
needs fixingDuring the move from paper to electronic records, staff could not locate some care plans and risk information when inspectors asked for them. The information was provided after the inspection.
“Staff were not able to locate some records when we asked for them but after the inspection the registered manager sent the information requested.” from the report
Medicine administration was not recorded
seriousIn one instance, staff did not record that medicines had been given. This could have led to an additional dose being given. The provider arranged further training and competency checks afterwards.
“This could leave people at risk of being given additional doses incorrectly because the first dose was not recorded.” from the report
Mealtimes could be more comfortable
minorMenus were not always visible, some people ate from attached tables rather than dining tables, and music was sometimes too loud. Inspectors made a recommendation about improving the mealtime experience.
“We recommend the provider explores best practice guidance around meal time experiences for people in large care homes.” from the report
Some areas needed better upkeep
needs fixingInspectors saw worn furniture and one cluttered area that could have affected access to fire exits. The area was cleared immediately.
“We also found one small section of the home to be cluttered which could prevent access to fire exits.” from the report
- 01What changes have been made to the two seizure risk assessments, and how are staff told what to do if a seizure happens?
- 02How do you make sure staff can quickly find the correct care plans and risk assessments on the electronic records system?
- 03What checks now confirm that every medicine dose has been recorded immediately after administration?
- 04What have you changed to improve menus, dining tables and noise levels during mealtimes?
- 05How are worn furniture and fire exit access checked and kept safe?
This was an unannounced inspection covering all five key questions, including infection prevention and control, and it looked at both the premises and the care provided. This explanation was written from the published report of 5 September 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 overall; inspectors found kind, organised care, but medicines safety required improvement.
The inspection was unannounced and took place on 03 July 2019. Inspectors observed care, spoke with people, relatives, staff and a visiting healthcare professional, and checked care records, staff files, medicines records and quality checks.
The overall rating was Good. Effective, caring, responsive and well-led were all rated Good. Safe was rated Requires Improvement because inspectors found expired medicines and saw an inhaler being given incorrectly.
The home had improved since the previous inspection, when it was rated Requires Improvement and had several breaches of regulation. At this inspection, it was no longer in breach of regulations, although inspectors recommended further improvement in handling and giving medicines.
Kind and respectful care
People and relatives said staff were kind and caring. Inspectors saw people being offered choices and supported with privacy, dignity and independence.
“People and relatives felt staff were kind and caring.” from the report
Personalised care plans
Care plans recorded people's choices, communication needs, faith, culture and care needs. They were reviewed monthly or sooner when needed.
“The care plans were personalised, which meant that people's views and choices of care they wanted were specified.” from the report
Staffing and training
Inspectors found enough staff to meet people's needs. Staff had induction, ongoing training, supervision and appraisal arrangements.
“People received care and support from staff who were well trained and supported.” from the report
Clean environment
The home was clean, with effective hand hygiene arrangements and no offensive smells reported by inspectors.
“The service was exceptionally clean and free from offensive smells.” from the report
Improved leadership
The home had introduced regular audits and external quality reviews. This followed the previous inspection's concerns about governance.
“The appointment of a new registered manager since our last inspection had resulted in improvements of the quality of the service.” from the report
Medicines safety
seriousExpired medicines were still present for people who no longer lived at the home. Inspectors also saw an inhaler being given incorrectly, so one person was not receiving their medicine as prescribed.
“We also observed the way staff administered inhalers for one person was not correct which meant the person was not receiving their medicine as prescribed.” from the report
- 01What action has been taken to remove expired medicines, and how is their disposal now checked?
- 02What has changed to make sure inhalers and other medicines are given exactly as prescribed?
- 03How are medicine audits followed up when they identify a problem?
- 04How often are my relative's care plan and risks reviewed, and can relatives take part in those reviews?
- 05How do you check that staffing levels continue to meet each person's assessed needs?
This was a planned inspection covering the overall service and all five rating areas, following the previous Requires Improvement rating. This explanation was written from the published report of 8 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 Ashbrook Nursing Home
4 rated inspections over 8 years: the service has held its Good rating throughout.
- September 2023Goodcurrent ratingstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2019Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 3 February 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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