CQC report explained · a residential care home
What the CQC found at Ashburton House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, July 2023
Ashburton House is rated Good overall, but inspectors found safety checks and records still needed improvement.
Inspectors visited unannounced on 22, 24 and 29 March 2023. They spoke with people living at the home, relatives, staff and health professionals. They observed care, checked records, medicines, recruitment files, the building and the grounds.
The overall rating improved from Inadequate to Good. The home was no longer in Special Measures and was no longer in breach of the eight regulations identified at the previous inspection. The new management and staff team had made significant improvements.
Care was described as kind, respectful and individual. Staff supported people's choices, health needs, meals, activities and relationships. Medicines were managed safely, and complaints, care records and work with health professionals had improved.
Safe was rated Requires Improvement. Some risks in bedrooms and the garden were not fully assessed or recorded. Two people could not reach their call bells, and cleaning issues were found at first but addressed during the inspection.
Kind and respectful care
Staff were attentive and treated people with dignity. Inspectors saw gentle, compassionate interactions and staff taking time to listen.
“People received kind and compassionate care from staff who used positive, respectful language which people appreciated.” from the report
Improved leadership
There had been major changes to the management and staff teams. Inspectors found a calmer atmosphere, better teamwork and stronger oversight.
“Since our last inspection, the provider had reflected on their role and how the service was run and staffed.” from the report
Personalised support
Care records gave staff useful information about people's preferences, communication and comfort. Staff adapted their approach to individual needs.
“We saw personalised information in care plans which gave important information to staff in how to work alongside people and maintain their dignity and trust.” from the report
Activities and relationships
People were supported to spend time with others and take part in activities linked to their interests and backgrounds. Activities included musicians, quizzes and trips out.
“There was a good range of social opportunities for people, including visiting musicians, quizzes, trips to the pub and cafes.” from the report
Some risks were not recorded
needs fixingRisk assessments did not always explain the risks from bedroom features or the garden railing. The provider made changes during and after the inspection, but records still needed strengthening.
“Records did not show how the risk of falling down the steps by the occupant or other people had been assessed.” from the report
Some people could not reach call bells
needs fixingTwo people could not reach their call bells. Staff said they would address this and said people staying in their rooms were checked regularly.
“Two people could not reach their call bell; staff said they would address this but assured us people who chose to stay in their room were checked regularly.” from the report
Cleaning needed attention at first
minorInspectors found that the kitchen and laundry needed more thorough cleaning on the first day. This was addressed, and a later visit confirmed infection control was being managed safely.
“On the first day of the inspection, we saw improvements were needed to ensure the kitchen and laundry were thoroughly clean.” from the report
Recruitment records needed more information
needs fixingSome recruitment files did not contain enough information to show how references had been obtained. This was addressed during the inspection.
“We looked at recruitment files for previously recruited staff and identified further information was needed to ensure people were suitable to work at the home.” from the report
- 01How are the risks from the bedroom steps, French doors and garden now assessed, recorded and reviewed?
- 02How do you make sure every person can call for help if they cannot use or reach a call bell?
- 03What checks now make sure the kitchen and laundry remain thoroughly clean?
- 04How do you check that recruitment files contain references and all other required information?
- 05What evidence can you show that the improvements made since the previous Inadequate rating are being maintained?
This was an unannounced inspection covering all five key questions, including infection prevention and control; the report compares the findings with the previous inspection published on 25 October 2022. This explanation was written from the published report of 13 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, October 2022
Rated Inadequate and placed in special measures; inspectors found widespread risks to people's safety, care and rights.
This was the first inspection since the home was registered with the current provider. It was unannounced and followed a notification about a person who died after a fall. Inspectors visited on four dates, spoke with people, relatives, staff and health professionals, and reviewed care, medicine, staffing and management records.
Inspectors found people were at risk from poorly managed falls, unsafe grounds, missing safeguarding action, too few evening staff, medicine problems and poor infection control. Staff did not always have the training or information needed to provide safe, personalised care. Some people also did not receive enough activities, privacy, dignity or help to express their choices.
The home was rated Inadequate overall. Safe, effective, responsive and well-led were rated Inadequate. Caring was rated Requires Improvement. The home was placed in special measures, meaning it would be kept under review and normally re-inspected within six months if its registration was not cancelled.
Some people felt safe
Some people and relatives said they felt safe, secure and well cared for at the home.
“Some people told us, "I feel safe here." And, "I feel safe and well cared for here, the staff are splendid.” from the report
Kind staff
People and relatives often described staff as kind, caring and pleasant, although inspectors also saw care that was not always respectful or person centred.
“Relatives said they were reassured because "The staff are lovely and they're very good with (Name)... they're patient and understand (Name)” from the report
Access to visitors
People were supported to receive visitors, and inspectors saw visitors during the inspection.
“People were being supported to have visitors and we saw people visiting during our inspection.” from the report
Some action after inspection
The report records that the unsafe shed and laundry were secured, a new medicines refrigerator was installed and staff received face-to-face dementia training after the inspection.
“Since the inspection, staff have received face to face dementia training from an external provider.” from the report
Serious safety risks
seriousThe grounds, laundry and shed were unsafe or unsecured, and known risks such as falls and malnutrition were not acted on promptly. The report says this placed people at risk of harm.
“Known risks were not well assessed, monitored or managed which put people at risk of harm.” from the report
Safeguarding failures
seriousIncidents involving aggression, a locked bedroom and possible abuse were not consistently recorded, referred to safeguarding agencies or reported to the regulator.
“There was a failure to protect people from abuse and improper treatment.” from the report
Medicines and infection control
seriousMedicine refrigerator temperatures were outside the required range for more than two months, and records showed some prescribed medicines were not given as agreed. Laundry arrangements and mask use also increased infection risks.
“Medicine records showed people did not always get their medicines in the way they were prescribed.” from the report
Insufficient staff preparation
seriousNew staff were not properly inducted or supervised, and several staff had not completed dementia training. Inspectors found there were not enough staff in the evening to keep people safe.
“New staff did not receive appropriate support and induction.” from the report
People's rights not protected
seriousCare records lacked mental capacity assessments and best-interest decisions. Some restrictions had not been included in appropriate legal applications, and inspectors found that people were sometimes restrained unlawfully.
“There was a failure to ensure that care was delivered with the consent of the relevant person.” from the report
Personalised care and complaints
needs fixingCare plans lacked personal preferences, communication guidance and end-of-life wishes. There was no effective, auditable complaints system, and complaint information was not accessible to everyone.
“There was no system to identify, record or respond to complaints.” from the report
- 01What has been done to prevent falls, including changes to the grounds, room allocation and referrals to falls specialists?
- 02How are evening staffing levels decided, especially when two staff are needed to help people move?
- 03How do you now check that medicines are stored at the right temperature and given exactly as prescribed?
- 04How are mental capacity assessments, best-interest decisions and required legal applications being completed and reviewed?
- 05Can we see how care plans now record each person's communication needs, preferences, activities and end-of-life wishes?
This was the first comprehensive inspection of the newly registered service and covered the premises and care provided; it followed concerns about a death after a fall. This explanation was written from the published report of 22 October 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 Ashburton House
4 rated inspections over 8 years: the service has held its Good rating throughout.
- July 2023Goodcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2022Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- August 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2021
Registered with the Care Quality Commission on 6 October 2021.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
17 live-in carers within about an hour of Devon
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,020 to £1,270 a week. 15 can care for a couple. 13 years' experience on average.
“She is such a warm and gentle person while being professional and competent at the same time.”
“She looked after my mum, who can be incredibly challenging, so well and so gently, and we always felt confident that my mum was getting the best care available.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.