CQC report explained · a residential care home
What the CQC found at Ashdene Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were assessed and reviewed, medicines were safely managed, staffing was sufficient, and systems were in place for safeguarding, fire safety and infection control.
- Effective?
- Good
- People's needs were assessed in detail, staff had the training needed for their roles, food and drink were well supported, and consent arrangements followed the Mental Capacity Act.
- Caring?
- Good
- Staff were kind, respectful and attentive. People were involved in their care, and inspectors found that privacy and dignity were maintained.
- Responsive?
- Good
- Care plans reflected people's wishes, histories and needs. People were supported with activities, religious and cultural needs, complaints and end of life care.
- Well-led?
- Good
- Leadership was visible and accessible. Audits and action plans were used to identify and address problems, and inspectors found clear improvement since the previous inspection.
What inspectors found, June 2019
Ashdene Care Home was rated Good; inspectors found safe, kind and personalised care, with a short-lived problem during one lunchtime.
Inspectors visited without warning on 25 and 26 March 2019. They spoke with people, a relative, staff and managers. They reviewed care records, staff files, medicines, complaints, accidents, audits and safety records.
The home was rated Good in all five areas. Inspectors found people were protected from abuse and avoidable harm, medicines were managed safely, staffing was sufficient, and care was based on people's needs and choices.
Staff were described as kind and caring. People had detailed, personal care plans and could take part in activities, make choices and raise concerns. The home also worked with health professionals and community groups.
At the previous inspection, published in October 2017, the home was rated Requires Improvement and breached Regulation 11 about consent. Inspectors found that this issue had been addressed and rated the home Good overall.
Safe care and medicines
Inspectors found that risks were managed and medicines were administered, stored and checked safely.
“People were safe and protected from avoidable harm. Legal requirements were met.” from the report
Kind and respectful staff
Staff knew people well and treated them with kindness, dignity and respect.
“Staff interactions with people living in the home was attentive and kind.” from the report
Personalised care
Care plans included people's histories, preferences and wishes. Staff used this information to understand and support each person.
“Each person had developed a 'My Life Story' document which described the person's life before moving into care.” from the report
Improvement since the last inspection
The home had acted on earlier problems with consent, medicines and quality checks. Inspectors found that governance and outcomes had improved.
“Evidence we saw confirmed that the registered provider had improved since the last inspection published on 10 October 2017.” from the report
Lunch organisation on one floor
needs fixingLunch was less organised in the first-floor dining area. Some people did not have cutlery and were not attended to promptly, although inspectors saw improvements the next day.
“In the first-floor dining area we observed that support provided to people was not as consistently positive.” from the report
- 01How do you make sure lunch is organised and people on the first floor receive prompt support?
- 02How do you check that the improvements to consent arrangements made after the previous inspection remain in place?
- 03How are medicines audits carried out, and what happens if a problem is found?
- 04What specialist training do staff now receive for positive behaviour and end of life care?
- 05How are residents and relatives involved in reviewing care plans and making changes to the service?
This was an unannounced scheduled inspection covering all five CQC questions, including the premises and care provided. This explanation was written from the published report of 26 June 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.
What inspectors found, October 2017
Rated Requires Improvement; inspectors found kind, responsive care but repeated problems with medicines and consent records.
The unannounced inspection took place on 23 August 2017. Inspectors spoke with people living at the home, relatives, staff, the manager, a visiting professional and a volunteer. They also looked at care plans, training records, audits and medicines.
People were treated kindly and respectfully. Inspectors found enough staff, personalised care, activities, support with food and access to health professionals. People and relatives said they felt safe and well cared for.
There were important shortfalls. Medicines were not always managed safely, and best-interest decisions for people who could not consent were not consistently recorded. The problem with consent had also been found at the previous inspection.
The overall rating was Requires Improvement. Caring and Responsive were rated Good. Safe, Effective and Well-led were rated Requires Improvement.
Kind and respectful care
Staff were patient, gentle and respectful when supporting people. Inspectors saw staff explain care and ask for permission before helping.
“Staff were kind and gentle when providing care to people.” from the report
Enough staff available
Inspectors found enough staff to meet people's needs. People were responded to promptly, and gaps were covered by staff familiar with the home.
“There was sufficient staff available to meet people's needs.” from the report
Personalised support
Care records included people's histories, preferences and practical needs. Staff used this information to understand people and plan activities.
“Care records were personalised and included information about what practical support people required.” from the report
Medicine records and guidance
seriousSome regular medicines were recorded as if they were only needed when required. Guidance for variable doses and as-required medicines was not consistently available, creating a risk that people received the wrong dose.
“People were at risk of not receiving the prescribed dose.” from the report
Consent and best-interest decisions
seriousBest-interest decisions were missing for some people who could not consent, including someone receiving medicines in food. Records also did not always clearly show who could legally consent.
“This was a breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Quality checks missed problems
needs fixingThe home's audits and policies had not identified the medicines issues found by inspectors. The medicines policy was also not up to date with national guidance.
“Arrangements for checking the quality of care had failed to identify the medicine issues we identified at the inspection.” from the report
Previous issue not fully resolved
needs fixingThe provider had not fully addressed the earlier concerns about the Mental Capacity Act and best-interest assessments.
“The provider had failed to fully address the issues raised at our previous inspection in relation to the MCA and best interest assessments.” from the report
- 01What changes have you made to ensure regular and as-required medicines are recorded and given correctly?
- 02How do you now provide clear instructions for medicines with variable doses?
- 03How do you record best-interest decisions for people who cannot consent to care or medicines?
- 04How do you check that relatives are legally able to consent on a person's behalf, and what decisions can they make?
- 05What has changed since the previous inspection, and how do your audits now identify these problems?
This was an unannounced inspection covering all five key questions, with checks of care plans, staff records, audits and medicines. This explanation was written from the published report of 12 October 2017 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 Ashdene Care Home
3 rated inspections over 3 years: the service has improved, from Requires improvement to Good.
- June 2019Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 19 November 2010.
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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9 live-in carers within about an hour of Lincolnshire
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.
8 can care for a couple. 10 years' experience on average.
“Martin was more than a carer, he managed the home and became my uncle's best friend, enriching his life during his last few years.”
“Magda was always positive and proactive about trying new things to keep dad busy. She also introduced new ideas for keeping dad healthy.”
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.