CQC report explained · a nursing home
What the CQC found at Ashfield House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risks linked to care, fire safety and medicines were not always identified, assessed or managed. People felt safe and there were enough staff, but some night-time call bells were not answered promptly.
- Effective?
- Requires improvement
- People had access to health professionals and staff generally knew people's needs. Some staff training was out of date, and advice from health professionals was not always clearly recorded.
- Caring?
- Good
- Staff were kind and respectful. People were involved in decisions, their independence was promoted and their privacy and dignity were upheld.
- Responsive?
- Requires improvement
- Most care plans checked were detailed and up to date, but some important care instructions were missing. People had limited opportunities to take part in activities they enjoyed, and a complaint had not been investigated.
- Well-led?
- Requires improvement
- The new management team had improved oversight and was trusted by people, relatives and staff. However, audits and other systems had not identified important safety and record-keeping problems, and the provider remained in breach of governance requirements.
What inspectors found, October 2022
Rated Requires Improvement; inspectors found kind care and progress since the last inspection, but safety, medicines and management systems still put people at risk.
This was an unannounced follow-up inspection on 28 September 2022. Inspectors spoke with people, relatives, staff and visiting health professionals. They observed care and checked care plans, medicines records, staff files and management records.
The home had improved from its previous Inadequate rating and was no longer in special measures. People were treated with kindness, staff knew them well and daytime staffing had improved. Infection control, safeguarding and recruitment had also improved.
However, some risks, including falls, choking, skin damage, fire safety and medicines, were not managed well enough. Some training and care records were incomplete. Activities were limited and one complaint had not been passed to the manager for investigation.
The overall rating and four of the five questions were Requires Improvement. Caring was rated Good. The provider remained in breach of Regulation 12 and Regulation 17, and CQC asked for an action plan and will monitor progress.
Kind and respectful staff
People and relatives described staff as caring. Inspectors saw positive relationships and found that people's dignity, rights and independence were promoted.
“People were supported by staff who they described as 'wonderful, brilliant and respectful'.” from the report
Improved management
A new management team had been in place for two months and had already addressed some important problems. Staff said they felt supported and morale had improved.
“Despite the management team only being in post for two months they had worked hard to address some of the key concerns we had found at the last inspection to benefit people.” from the report
Better staffing
The report says staffing had improved since the previous inspection. People reported that daytime staff usually responded quickly, and recruitment checks were completed safely.
“People told us the availability and consistency of staff during the daytime had improved.” from the report
Improved infection control
Inspectors were assured that the home was using protective equipment safely, managing visits and admissions safely, and following infection prevention guidance.
“We were assured the provider's infection prevention and control policy was up to date in line with current guidance and implemented effectively to prevent and control infection.” from the report
Improved food and mealtimes
People's feedback about food had improved. Inspectors saw tables prepared for meals and staff supporting people in a relaxed and friendly way.
“The mealtime experience had improved. Tables were laid with cloths, cutlery and condiments.” from the report
Risks were not consistently managed
seriousSome risks, including choking, falls, skin damage and fire safety, were not properly assessed or followed up. This created a risk of avoidable harm.
“Systems and processes were not sufficient to demonstrate risk was identified, assessed and mitigated. This exposed people to the risk of avoidable harm.” from the report
Medicines records were unsafe
seriousRecords did not always show that creams had been applied, where patches had been placed or when some medicines had been given. A controlled drugs record was also signed when the administration had not been witnessed.
“We found no evidence that people had been harmed however systems and processes were not sufficient to demonstrate people's medicines were managed and administered safely.” from the report
Important training was overdue
needs fixingSome staff training, including infection control and catheter care, was not up to date. The manager said action was planned.
“Training for some staff was not up to date, including infection control and catheter care.” from the report
Activities were limited
needs fixingPeople did not always have enough opportunities to spend time doing things they enjoyed. The home was planning to recruit an activities coordinator.
“People continued to have limited opportunities to spend their time doing things they enjoyed and were of interest to them.” from the report
A complaint was not investigated
needs fixingA complaint recorded by staff was not brought to the manager's attention because the required box was not ticked. The manager only became aware after inspectors raised it.
“However, staff had not ticked the necessary box on the system to ensure the complaint was bought to the managers attention for them to address.” from the report
Audits missed safety problems
seriousThe provider's audits did not identify the medicines and other problems found during the inspection. This meant opportunities to improve safety were missed.
“Despite the introduction of regular structured audits and checks since our last inspection the issues we found had not been identified.” from the report
- 01What has been done to make sure every person's risks, including falls, choking and skin damage, are assessed and followed by staff?
- 02How are medicines now checked, including creams, patches, controlled drugs and medicines bought without a prescription?
- 03What changes have been made to fire safety checks and repairs to bedroom doors?
- 04How many activities are now available each week, including at weekends, and how are residents' interests used to plan them?
- 05How are complaints recorded, passed to the manager and investigated?
This was an unannounced follow-up inspection of all five key questions after the previous Inadequate inspection, and it also checked infection prevention and control measures. This explanation was written from the published report of 18 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, April 2022
Rated Inadequate and placed in special measures; inspectors found serious risks to safety, staffing, dignity and management.
This was an unannounced inspection on 8 and 13 December 2021. Inspectors spoke with people, relatives and staff, observed care, and checked care records, medicines records, staff files and management records. They also checked infection prevention and control.
Inspectors found people were at risk because falls, catheters, pressure damage, fire safety, medicines and infection control were not managed safely. There were not always enough staff, and some agency staff had not received an induction. Safeguarding concerns had not always been referred or investigated.
People did not always receive care that respected their privacy, dignity, choices or individual needs. Records were sometimes inaccurate or out of date. Activities were limited, complaints were not properly recorded, and people and relatives had not been given enough opportunities to provide feedback.
The overall rating fell from Requires Improvement to Inadequate. Safe and Well-led were rated Inadequate. Effective, Caring and Responsive were rated Requires Improvement. The home was placed in special measures, meaning CQC said it would keep the service under review and normally re-inspect within six months.
Regular staff were valued
People and relatives spoke positively about permanent and regular agency staff. Some staff knew people well and tried to follow their wishes.
“People and relatives spoke highly of the permanent and regular agency staff.” from the report
Access to professionals
People had access to health and social care professionals. When advice was obtained, it was recorded and followed.
“People had access to a range of health and social professionals.” from the report
Information in different formats
Information about the service was available in formats including large print. Care records also included some information about communication needs.
“Information including information for people about the service was available in a variety of formats including large print.” from the report
Risks were not controlled
seriousInspectors found missed checks for falls and repositioning, unsafe catheter arrangements, fire safety risks and inaccurate emergency information. These failures placed people at risk of avoidable harm.
“Systems and processes were not sufficient to demonstrate risk was identified, assessed and mitigated.” from the report
Safeguarding was not followed
seriousTwo allegations of abuse had not been referred or investigated. Some staff also did not understand when they needed to escalate a safeguarding concern.
“The registered manager had not made safeguarding referrals or conducted an investigation following two separate allegations of abuse.” from the report
Not enough consistent staff
seriousPeople, relatives and staff reported low staffing levels and heavy use of agency workers. This affected response times, consistency and the time available for person-centred care.
“The provider had failed to ensure there were sufficient numbers of staff available to meet people's needs” from the report
Dignity and privacy were not reliable
seriousSome people waited for personal care, entered rooms were not always approached with permission, and staff language was not always respectful.
“We found no evidence that people had been harmed however, people's privacy and dignity was not always considered and promoted and their preferences respected.” from the report
Care records were inaccurate
needs fixingSome care plans were out of date or conflicting, and daily records did not always show that planned care had been given. This made it harder for staff to provide safe, personalised care.
“Care records did not always provide staff with the information they needed to deliver personalised, safe care and some records contained conflicting, out of date information.” from the report
Weak management oversight
seriousAudits and other governance systems did not identify the problems found by inspectors. The provider had not learned lessons or sustained improvements from the previous inspection.
“The provider had not learned lessons since our last inspection and the overall quality and safety of the service provided to people had deteriorated.” from the report
- 01How many permanent and agency staff are now on each shift, and how do you check that staffing meets each person's needs?
- 02How are falls, catheter care, repositioning, fire safety and oxygen use now assessed and checked?
- 03How do you make sure every agency worker receives an induction and knows each person's risks and emergency evacuation plan?
- 04How are safeguarding concerns, complaints and accidents now recorded, referred, investigated and reviewed?
- 05How have care plans and daily records been checked to ensure they are accurate, current and personalised?
This was an unannounced planned inspection covering all five key questions, including infection prevention and control; all five ratings were based on this inspection, with the overall rating falling from Requires Improvement to Inadequate. This explanation was written from the published report of 9 April 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 Ashfield House
9 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- October 2022Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2022Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- February 2021Requires improvementup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2020Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- May 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- April 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- August 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2015Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2020
Registered with the Care Quality Commission on 9 December 2020.
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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At least 100 live-in carers within about an hour of Coventry
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 £950 to £1,260 a week. 80 can care for a couple. 11 years' experience on average.
“If you bump into her in the night on her way to the bathroom she will still inquire how you are and if everything is alright.”
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