CQC report explained · a nursing home
What the CQC found at Ashdowne Care Centre
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, November 2022
Rated Requires Improvement; inspectors found uneven staffing, safety checks and quality monitoring, although managers took action during the inspection.
Inspectors visited without warning on 6 and 18 October 2022. They spoke with people, relatives and staff, observed care, and checked care, medicines, recruitment, safety and management records.
The home was not always safe. People on one unit sometimes waited for help because staffing levels were short. Inspectors also found problems with call bells, a pressure mattress, fluid monitoring, medicines records, cleanliness and damaged bed bumpers.
Managers acted during and after the visits. They changed staffing arrangements, checked call bells, improved records, covered radiators, replaced damaged bed bumpers and strengthened audits. However, some problems had not been found by the home's own checks.
The overall rating changed from Good to Requires Improvement. Safe and Well-led were both rated Requires Improvement. The other key questions were not inspected during this visit and their previous ratings were carried forward.
Safeguarding awareness
People said they felt safe. Staff had safeguarding training and knew how to respond to possible abuse.
“Staff had completed safeguarding training. Staff spoken with had completed safeguarding training and were aware of the different types of abuse.” from the report
Action taken quickly
Managers responded to concerns raised during the visits. They made changes to call bells, radiators, bed bumpers and records.
“On the second day of our visit the manager had completed an action plan about the concerns we discussed at the end of the first day.” from the report
Fire and emergency planning
Fire checks and drills were carried out, equipment was tested, and emergency evacuation plans were in place.
“There were individual personal emergency evacuation plans for people in place to keep people safe in an emergency and staff understood these and knew where to access the information.” from the report
Uneven staffing
seriousThe Ashdowne unit was short of staff during the inspection. This meant some people waited for help and care was not always delivered promptly.
“However, on the Ashdowne unit we observed they were short of staff which meant people's care needs were not always met promptly.” from the report
Safety checks were missed
seriousOne person did not have a working pressure mattress and some people did not have access to a call bell. Fluid monitoring was also not clear.
“On the Ashdowne unit people did not always have access to a call bell, although they were able to use the bell to alert staff to their needs.” from the report
Cleanliness and equipment
needs fixingSome areas were dirty and some bed-rail bumpers were ripped and difficult to clean. Managers fixed these issues, but the home's checks had not found them.
“We found some bed rail bumpers were ripped and breached and therefore not easy to clean.” from the report
Audits did not find problems
needs fixingThe home's audit programme was in place, but it had not identified several concerns found by inspectors. Managers produced an action plan to improve monitoring.
“At the inspection we highlighted areas of concern which had not been identified by the program of audits.” from the report
Medicines records
needs fixingRecords did not confirm whether some prescribed supplements had been given. Two as-needed medicines protocols were also missing, although these were added during the inspection.
“However, the medicines administration records (MAR) did not confirm if these had been given as prescribed.” from the report
- 01How do you make sure the Ashdowne unit has enough staff when there is short-notice absence?
- 02How do you check every person's call bell and pressure-relieving equipment each day?
- 03How do you record and review drinks, weight-loss supplements and other medicines?
- 04What changes have you made to cleanliness and infection-control audits since this inspection?
- 05How will you show that the improved staffing and audit arrangements have continued?
This inspection focused on Safe and Well-led; the other key-question ratings were not inspected and were carried forward from the last inspection. This explanation was written from the published report of 22 November 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, August 2021
Ashdowne Care Centre was rated Good overall, but inspectors found safety needed improvement, mainly because staffing sickness still caused pressure.
This was an unannounced focused inspection on 27 July and 2 August 2021. Inspectors looked at Safe, Effective and Well-led after concerns about staffing, training and management culture. They spoke with people, relatives, staff and a healthcare professional, observed care and meals, and checked records.
People generally felt safe and relatives were mostly confident in the care. Recruitment, medicines, fire safety and infection control were managed well. Staff training had improved, people's health needs were monitored, and managers had quality checks in place.
Safety remained Requires Improvement because staff sickness and turnover put pressure on staff. Inspectors also found problems with some support at mealtimes and noted that some people and relatives were unclear about visiting arrangements. The overall rating stayed Good, but the Safe rating did not improve.
Safeguarding and risk checks
Staff understood different types of abuse and how to report concerns. Individual risks such as falls, poor nutrition and skin damage were assessed and monitored.
“Staff had received safeguarding training and demonstrated an understanding and awareness of the different types of abuse.” from the report
Medicines
Staff who gave medicines had training and competency checks. A recent pharmacy visit found no significant concerns, and medicine rounds had been made shorter.
“Medicines were safely managed. All staff that were administering medicines had received training around the safe use of medicines and their competency had been assessed.” from the report
Infection control
Inspectors were assured that the home was using protective equipment safely, following infection control guidance and managing visits in line with current guidance.
“We were assured that the provider was using PPE effectively and safely.” from the report
Staff skills and health monitoring
Training oversight had improved, and staff had the knowledge to support people's needs. People's physical and mental health was monitored so action could be taken when needed.
“People's physical and mental healthcare needs were being well-monitored to recognise any signs of deteriorating health so action could be taken.” from the report
Quality monitoring
Managers carried out monthly quality audits and reviewed accidents and incidents for patterns. They also responded to feedback from inspectors and staff.
“The operations manager worked closely with the registered manager. They undertook monthly quality monitoring audits and actioned any concerns.” from the report
Staff sickness and call-bell waits
seriousHigh sickness levels and staff turnover continued to affect the home. People and staff said that call-bell response times and staffing consistency could vary.
“The call bell being answered depends who is working. Sometimes it is quite good other times it is a very long wait” from the report
Support at mealtimes
needs fixingInspectors observed staff standing over a person, not positioning someone correctly, giving large spoonfuls and not responding when food was spilled. Managers said they had addressed this with staff.
“Three staff members did not show care and attention when supporting people with their meals.” from the report
Communication and management presence
needs fixingSome staff felt the manager was not at the home regularly enough and did not communicate well. The management team accepted the feedback and said it would improve communication.
“He is a good manager but doesn't communicate very well and this often causes upset.” from the report
Visiting information
minorVisits were being facilitated in line with guidance, but some people and relatives were not clear about the government's guidance and the home's visiting arrangements.
“Although some people and relatives were not always clear about the government's guidance and the visiting arrangements at the home.” from the report
Communal toiletries
needs fixingToiletries were left in communal bathrooms. Inspectors said this could pose a risk to people who might not understand what the chemicals were.
“This could pose a risk to people who may not have an understanding of what the chemicals were and use them unsafely.” from the report
- 01How many staff are now on duty in each unit during the day and night?
- 02How do you cover short-notice sickness, and what are current call-bell response times?
- 03What changes have been made to support people safely and respectfully during meals?
- 04How are visiting rules explained to residents and relatives, and how are changes communicated?
- 05How often is the registered manager at the home, and what management support is now in place?
This was a focused inspection of Safe, Effective and Well-led; the other key question ratings were not inspected and previous ratings were used for the overall rating. This explanation was written from the published report of 21 August 2021 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 Ashdowne Care Centre
9 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- November 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2021Goodstayed GoodSafe: Requires improvementWell-led: Good
- September 2020Goodup from Requires improvementSafe: Requires improvementWell-led: Good
- July 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodWell-led: Requires improvement
- June 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- April 2017Goodstayed GoodEffective: Good
- June 2016Goodup from Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- October 2015Requires improvementstayed Requires improvementEffective: Requires improvementResponsive: GoodWell-led: Good
- May 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2014
Report published without a new overall rating.
- August 2014
Report published without a new overall rating.
- April 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- May 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 10 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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