CQC report explained · a nursing home
What the CQC found at Ashcroft Hollow Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People had current risk assessments and clear guidance for staff. Medicines, recruitment, safeguarding and infection control were managed effectively.
- Effective?
- Good
- People's needs were assessed and reviewed, and staff were trained. People received support with nutrition, healthcare, consent and their individual needs.
- Caring?
- Good
- People were treated with kindness and respect. Staff supported people's privacy, dignity, independence and involvement in decisions.
- Responsive?
- Good
- Care was personalised to people's needs and preferences. People could take part in activities, maintain relationships and raise concerns.
- Well-led?
- Good
- The provider had improved its quality checks and promoted an open, person-centred culture. Some records were still being improved, including life histories and repositioning charts.
What inspectors found, October 2022
Ashcroft Hollow Care Home was rated Good; inspectors found safe, kind and personalised care, with some records still being improved.
This was an unannounced follow-up inspection on 15 and 21 September 2022. One inspector spoke with six people, one relative, seven staff members and an external professional. They also checked care and medicines records, staff files, training records, audits and policies.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough safely recruited staff, safe medicines systems, suitable infection control, trained staff and good support with eating, drinking and healthcare.
People said staff were kind and respected their privacy, dignity, choices and independence. The home provided personalised care, activities and support to maintain relationships. Complaints and end of life wishes were also recorded and acted on.
The previous rating was Requires Improvement, published in October 2020, with breaches of regulation. The provider had made improvements, including better risk assessments and quality checks, and was no longer in breach at this inspection.
Current risk information
Risk assessments were up to date and reflected people's current needs. Staff had clear information about how to reduce risks such as falls, pressure damage and problems with eating and drinking.
“People's care records now contained specific information of risk prevention strategies which guided staff on how to effectively support them.” from the report
Safe medicines and infection control
Inspectors found effective systems for medicines and were assured that infection risks were being managed, including the safe use of protective equipment.
“The provider had effective systems in place to safely manage people's medicines.” from the report
Kind and respectful care
People described staff positively. Inspectors saw staff spending meaningful time with people and respecting privacy, dignity and independence.
“People were well treated and supported to express their views and were involved in their care.” from the report
Personalised support and relationships
Care plans recorded people's preferences and interests. People were supported with activities and to keep in touch with relatives, including through video calls.
“People were supported to follow their interests and maintain relationships which were important to them.” from the report
Improved management
The provider strengthened its quality checks after the previous inspection. The manager used audits to identify issues and track improvements.
“The provider had updated their quality assurance processes in place to ensure they identified areas for improvement and actioned any concerns.” from the report
Repositioning records
needs fixingInspectors found some gaps in electronic repositioning charts. They found no impact on people and the manager took immediate action, but families should ask how recording is now checked.
“We found some gaps in people's electronic repositioning charts, we found no impact and staff were completing the repositioning during other aspects of people's care.” from the report
Life history information
minorSome care records did not yet contain enough information about people's life histories and social backgrounds. The home was working to add this information.
“Through the audits in place the registered manager had identified some people's life history and social record did not contain enough information.” from the report
Busy staffing periods
needs fixingSome people and staff said staff could be busy when the home was short staffed. They said people's needs were still met, but this is worth discussing for someone needing regular or urgent support.
“Whilst some people and staff told us sometimes staff were busy if they were short staffed, however, they confirmed people's needs were always met.” from the report
Capacity assessments being updated
minorThe home had completed capacity assessments and made appropriate applications for authorised restrictions. The manager was still updating assessments so that they related to specific decisions.
“The registered manager was in the process of updating these to ensure they were decision specific.” from the report
- 01How are electronic repositioning records now completed and checked after the gaps found by inspectors?
- 02How will you make sure each person's life history and social information is included in their care plan?
- 03What staffing levels are planned for each shift, and what happens when the home is short staffed?
- 04Have the capacity assessments now been updated so that each decision is considered separately?
- 05How are people's personal preferences, activities and contact with relatives recorded and reviewed?
This was an unannounced follow-up inspection prompted by the previous inspection; it reviewed all five key questions, with infection prevention and control specifically considered under Safe. This explanation was written from the published report of 26 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.
What inspectors found, October 2020
Rated Requires Improvement; inspectors found improvements in staffing, medicines and infection control, but care records and quality checks were still not reliable.
This was a focused inspection on 14 September 2020. Inspectors looked at whether the home was safe and well-led. They spoke with people, relatives, managers and staff, observed care and checked records.
The home had enough staff and people received timely help. Medicines were managed safely, the home was clean, and infection control arrangements were in place. People said they felt safe.
However, some risk assessments and care records were out of date or incomplete. Quality checks did not reliably identify these problems. Mental Capacity Act processes were also not always followed.
The overall rating improved from Inadequate to Requires Improvement. The home is no longer in special measures, but it remains in breach of Regulation 17 and must continue making improvements.
Enough staff
Inspectors found enough staff to respond promptly to calls for help, mobility needs, toileting and meals.
“We found that people were supported by a sufficient number of staff.” from the report
Safe medicines
Records showed that medicines were given as prescribed. Staff were trained and their competence was checked.
“People had their medicines managed safely and records demonstrated people had received their medicines as prescribed, in a way they preferred.” from the report
Infection control
The home was clean, staff used appropriate protective equipment and new admissions were isolated for 14 days.
“We were assured that the provider was using PPE effectively and safely.” from the report
Positive relationships
People and relatives described staff as caring and responsive. Staff aimed to treat people as individuals.
“Staff worked hard to treat everyone as an individual ensuring their needs were met in their chosen way.” from the report
Out-of-date risk assessments
seriousSome risk assessments had not been updated for several years. Care files did not always explain the steps staff should take to prevent risks.
“We found some risk assessments had not been updated since 2017 or 2018.” from the report
Incomplete care records
seriousRecords did not always show why people needed repositioning, why fluid intake was monitored or whether some health checks had taken place.
“People's care files did not appropriately identify strategies for risk prevention, to allow staff to ensure people's care was been managed in a safe way.” from the report
Weak quality checks
seriousAudits checked whether documents existed but did not reliably check whether they were current or complete. This left risks unidentified.
“Quality assurance processes in place were not effective.” from the report
Mental Capacity Act gaps
seriousSome mental capacity assessments were incomplete and best-interest decisions were not always recorded where people might be unable to decide for themselves.
“People's rights under the Mental Capacity Act were not always fully protected.” from the report
Recruitment records
needs fixingThe manager could not always show enough evidence that staff were suitable and of good character, including reference checks.
“However, the manager could not always demonstrate they had satisfactory employment evidence of staff members' characters.” from the report
- 01How often are each person's risk assessments reviewed, and how do you make sure changes are recorded?
- 02How do care plans explain why someone needs repositioning or fluid monitoring, and how often this should happen?
- 03What checks now make sure mental capacity assessments and best-interest decisions are complete?
- 04What evidence do you keep to confirm every staff member has suitable references and character checks?
- 05What improvements are included in your monthly action plan, and can families see the progress?
This was a focused inspection of Safe and Well-led only; the other ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 27 October 2020 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 Ashcroft Hollow Care Home
8 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- October 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2020Requires improvementup from InadequateSafe: Requires improvementWell-led: Requires improvement
- January 2020Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- December 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- December 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- September 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: Requires improvementWell-led: Good
- September 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 14 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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