CQC report explained · a residential care home
What the CQC found at Ashdown House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, April 2023
Rated Good and no longer in special measures; inspectors found safe, kind care but leadership systems still needed improvement.
This was an unannounced follow-up inspection on 28 and 30 March 2023. Inspectors observed care, spoke with people, relatives and staff, and checked care, medicines, recruitment and management records.
The home was rated Good overall. Safe, Effective, Caring and Responsive were all rated Good. Inspectors found improvements in risk management, staffing, medicines, training, personalised care, activities and communication.
Well-led was rated Requires Improvement. The home had improved its checks and audits, but these systems needed more time to become fully established. There was no registered manager at the time, although a new manager had applied to register.
The previous inspection had rated the home Inadequate and placed it in special measures. Inspectors found the home was no longer in breach of regulations and was no longer in special measures.
Improved safety
The home had fixed earlier safety problems, including risks from hot surfaces, unsecured furniture, moving and handling, fire safety and the call bell system.
“Enough improvement had been made and sustained at this inspection and the provider was no longer in breach of Regulation 12.” from the report
Kind and respectful care
People said staff were kind, gentle and attentive. Inspectors saw staff protect people's privacy and ask permission before providing care.
“Carers [staff] are kind and gentle-smiling and ready to help…they know most of things about me, remind me to drink water or ask if I need anything.” from the report
Personalised support
Care plans recorded people's needs, preferences and communication requirements. People and relatives were involved in creating and reviewing care plans.
“People and their relatives, where appropriate, had been involved in creating and updating people's care plans.” from the report
Activities and family contact
People were supported to stay in contact with relatives and had group and individual activities available. The activities coordinator asked people what they wanted to do.
“People spoke positively about the activities available to them.” from the report
Safer medicines practice
Medicines were received, stored, given and disposed of safely. Staff had training and their ability to manage medicines was checked.
“Staff received training in the administration of medicines and their competencies were assessed before they could administer any medicines.” from the report
Quality systems not yet established
needs fixingThe new audit and monitoring systems had improved but were not yet fully embedded. Inspectors could not yet be sure they would remain effective over time.
“These needed to be embedded and sustained for us to fully assess their effectiveness.” from the report
Water safety oversight
needs fixingWater safety processes were in place but needed further improvement so that responsibilities and checks were consistently maintained.
“Water safety management systems and processes were in place but required further improvement to ensure the provider and manager had full oversight of what was required, and processes were consistently maintained and embedded.” from the report
People waiting for meals
needs fixingSome people were taken to the dining table earlier than needed and left waiting for their meal. The manager and provider agreed to review this.
“However, people were assisted to the table earlier than needed and left waiting.” from the report
Manager registration pending
minorThere was no registered manager when inspectors visited. A new manager had applied to register, and the application was still being assessed.
“There was no registered manager. A manager had been appointed and was in the process of applying to be registered.” from the report
- 01How are you checking that the new quality audits and safety checks remain effective?
- 02What specific changes have been made to water safety checks, and who is responsible for them?
- 03How will you prevent people being taken to the dining room too early and left waiting?
- 04Has the manager's application to become registered been completed, and who is responsible for the home while this is being assessed?
- 05What further refurbishment or garden improvements are planned, and how are people involved in deciding them?
This was an unannounced follow-up inspection after a previous Inadequate rating; inspectors assessed all five key questions and also checked infection prevention and control under Safe. This explanation was written from the published report of 22 April 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, December 2022
Rated Inadequate and placed in special measures; inspectors found serious safety and management failures, although medicines and safeguarding were handled safely.
This was an unannounced focused inspection on 12, 13 and 17 October 2022. Two inspectors and an Expert by Experience spoke with people, relatives and staff. They also checked care, medicines, recruitment and management records.
The home was not safe. People faced risks from unsecured furniture, missing radiator protection, poor fire checks, unsafe windows and a call bell that could not be heard everywhere. Staffing was not always sufficient, and some people did not receive timely help with meals or care.
The home was rated Requires Improvement for Effective and Inadequate for Safe and Well-led. Inspectors found that improvements promised after the previous inspection had not been completed. The overall rating changed from Requires Improvement to Inadequate.
Medicines
Inspectors found that medicines were received, stored, given and disposed of safely. Staff were trained and checked as competent before giving medicines.
“Medicines were safely managed. Safe protocols for the receipt, storage, administration and disposal of medicines were followed.” from the report
Safeguarding
Staff understood how to recognise and report possible abuse. People and relatives told inspectors they felt safe and that staff were caring and kind.
“People were cared for safely and were protected from the risk of harm.” from the report
Person-centred care plans
People had care plans describing their needs and preferences. Inspectors saw improvements in the detail available to guide staff.
“Care plans had been improved and were now person-centred.” from the report
Choice and consent
Inspectors found that people's rights were respected. Staff supported people to make decisions and used best-interest processes when needed.
“People's rights under the MCA were respected, consent was gained, and people were supported to live their lives independently.” from the report
Serious environmental risks
seriousPeople were exposed to risks from unsecured wardrobes, missing radiator protection, unsafe windows and incomplete fire checks. These problems had also been identified previously and had not been fixed.
“People were at risk from fire. The provider had failed to ensure all fire safety procedures and checks had been carried out.” from the report
Staffing and mealtime support
seriousStaff had extra cleaning, laundry and meal duties. Inspectors found that people who needed help to eat did not always receive it promptly, and staff numbers were lower at weekends.
“Staff were stretched and did not have the time to sit with people who needed assistance.” from the report
Moving and handling
seriousInspectors saw unsafe moving and handling, including a person being hoisted in a twisted sling and seated without wheelchair brakes or a lap belt. Further training was provided after the inspection.
“People were placed at risk of harm by poor manual handling techniques.” from the report
Fire and water management
seriousFire equipment and alarm checks were not reliably completed. Records for water safety checks were also missing, creating risks of infection and scalding.
“Water safety management systems and processes were not sufficient.” from the report
Weak management oversight
seriousAudits did not reliably identify safety and cleaning problems. The home had no registered manager at the inspection, and important issues raised by families had not been addressed.
“The provider failed to ensure systems and processes were in place to assess, monitor and improve the quality and safety of the care provided.” from the report
- 01What has been done to secure wardrobes, fit radiator protectors, repair unsafe windows and make the garden safe and accessible?
- 02How can you show that the call bell system can be heard throughout the home, including at night?
- 03What staffing levels and additional staff are now in place at weekends and during mealtimes?
- 04How are fire appliance checks, fire alarm tests and staff evacuation practice now recorded and monitored?
- 05Who is managing the home now, and what evidence can you provide that the action plan is being completed?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected during this visit, and the overall rating was based on the findings and previous ratings. This explanation was written from the published report of 9 December 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 Ashdown House
4 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- April 2023Goodcurrent ratingup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2022InadequateSafe: InadequateEffective: Requires improvementWell-led: Inadequate
- November 2021Inspected but not ratedSafe: Inspected but not rated
- May 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- September 2019Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2018
Registered with the Care Quality Commission on 21 August 2018.
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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