CQC report explained · a nursing home
What the CQC found at Ashfield Nursing & Residential Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- The home had enough staff and medicines were mostly managed safely. However, fire safety arrangements were not compliant, some recruitment checks were incomplete, and one safeguarding referral was not sent to CQC.
- Effective?
- Good
- People's needs were assessed and care plans reflected their choices. Inspectors found good support with food, healthcare and decision-making, although some staff training was not up to date.
- Caring?
- Good
- People described staff as kind and caring. Staff knew people well, respected their dignity and privacy, and supported independence and everyday choices.
- Responsive?
- Good
- Care plans were person-centred and staff understood people's individual needs. Activities, family contact and complaints processes were in place, although some people wanted more activities.
- Well-led?
- Requires improvement
- Quality checks did not reliably identify or correct risks. Audits, training records, staff supervision records and notification arrangements were not consistently effective, although people and staff described an open and positive culture.
What inspectors found, November 2023
Rated Requires Improvement; inspectors found kind, personalised care, but safety checks and management oversight were not reliable.
This was an unannounced inspection on 10 and 11 October 2023. Inspectors spoke with people, a relative, staff and managers. They looked around the building and reviewed care records, staff files, medicines records and management records.
The home was rated Requires Improvement overall. Safe and well-led were both Requires Improvement. Inspectors found fire safety problems, gaps in staff recruitment checks, overdue training and weak quality checks. One safeguarding incident had not been reported to CQC.
Effective, caring and responsive were rated Good. People said they felt safe and that staff were kind. Care plans were personalised, people were supported to make choices, and complaints were handled appropriately. The previous overall rating was Good in 2017.
Kind and familiar staff
People said staff were kind, helpful and respectful. Inspectors saw friendly interactions and found that staff knew people well.
“The staff by and large are good; I am familiar with them, it's a stable staff team year in and year out which is really handy because you can build a good relationship.” from the report
Personalised care
Care plans recorded people's needs, preferences, likes and dislikes. Staff could explain how they supported each person.
“Care plans were person centred and accurately informed staff about people's needs.” from the report
Choice and independence
People were involved in decisions about their care and could make everyday choices, such as when to get up, where to eat and where to sit.
“People were supported to maintain their independence and care plans reflected this.” from the report
Support with health and food
People were supported to access health professionals and received choices about food. Staff supported people to eat and drink calmly and respectfully.
“We saw people had involvement from dieticians, tissue viability nurses, general practitioners (GPs) and community nurses.” from the report
Complaints were handled
People and relatives knew how to raise concerns. Complaints were recorded, acknowledged and followed up with actions.
“People and relatives were able to make complaints or raise concerns, and these were responded to appropriately.” from the report
Fire safety problems
seriousA recent fire inspection found that the home was not compliant with fire regulations. Fire doors and the risk assessment were inadequate, and staff had not completed fire drills.
“A recent fire inspection showed the home was not compliant with fire regulations.” from the report
Weak management checks
seriousAudits did not consistently identify risks or show how problems had been fixed. This led to a breach of Regulation 17.
“Systems and processes failed to adequately assess, monitor and drive improvement in the quality and safety of the services provided.” from the report
Staff recruitment checks
needs fixingSome staff did not have references from previous employers. The report recommends reviewing the recruitment policy and guidance.
“Staff were not always recruited safely.” from the report
Overdue and missing training
needs fixingMore than half of staff had not completed fire safety and nutrition training. Training for epilepsy and catheter care had not been made available to staff.
“Over half of the staff team had not refreshed their fire safety and nutrition training.” from the report
Worn parts of the building
minorSome communal carpets and décor were worn and tired. Some areas also lacked signs to help people find their way around.
“However, parts of the home were worn and tired, including communal carpets and décor.” from the report
- 01What action has been completed to correct the fire door, fire risk assessment and fire drill problems?
- 02Has the fire service re-inspected the home, and what were the results?
- 03How do you now make sure every new staff member has suitable employment references?
- 04How many staff have completed the overdue fire safety and nutrition training, and what training is available for epilepsy and catheter care?
- 05How are audits, staff supervision and CQC safeguarding notifications now checked by managers?
This was an unannounced inspection covering all five key questions and infection prevention and control, with the previous ratings used as a comparison. This explanation was written from the published report of 29 November 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, February 2022
Ashfield Nursing & Residential Home was inspected but not rated; inspectors found good COVID infection control and visiting arrangements.
This was an announced, targeted inspection on 27 January 2022. Inspectors gave the home one day's notice. They focused on infection prevention and control, visiting arrangements and any staffing pressures linked to COVID-19.
Inspectors found supplies of protective equipment, hand-washing facilities and cleaning schedules. Staff had infection control training. The home was also carrying out COVID testing and had procedures for symptoms or positive tests.
The home was meeting the vaccination requirement for non-exempt staff and visiting professionals. Inspectors were assured that visits were being supported safely and that residents' social and emotional wellbeing was supported.
The service was marked 'Inspected but not rated'. This means the inspection did not give an overall quality rating or a rated judgement for the other areas of care.
Infection control planning
The home had policies and procedures for managing COVID-related risks. Inspectors found its infection control policy was up to date.
“The home had a range of policies and procedures to manage any risks associated with the COVID pandemic.” from the report
PPE, cleaning and hygiene
There were enough protective supplies, hand-washing facilities and hand sanitiser. Cleaning schedules covered regular touch points and deeper cleaning.
“Daily, weekly and monthly cleaning schedules were in place, which included touch point and deep cleaning.” from the report
Testing and visiting
Residents and staff were tested in line with guidance. Visitors were screened, and the home had procedures for symptoms and positive tests.
“A programme of COVID testing for both people living in the home and staff was undertaken in line with current government guidance.” from the report
Residents' wellbeing
Staff supported residents' social and emotional wellbeing during the pandemic. Residents could attend external events with risk assessments and testing.
“Staff supported the social and emotional wellbeing of residents and had done so throughout the pandemic.” from the report
Inspectors raised no specific concerns in this report.
- 01What infection prevention and control arrangements are in place now, and when were they last reviewed?
- 02How do you currently manage visits from family members and healthcare professionals?
- 03How do you respond if a resident or staff member has COVID symptoms or tests positive?
- 04How do you manage staffing pressures related to illness or COVID outbreaks?
- 05How do you make sure visiting staff and professionals meet the current vaccination or exemption requirements?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-related staffing pressures; it did not rate the other care areas or give an overall rating. This explanation was written from the published report of 24 February 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 Nursing & Residential Home
3 rated inspections over 9 years: the service has slipped, from Good to Requires improvement.
- November 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Ashfield Nursing & Residential Home →
- February 2022Inspected but not ratedSafe: Inspected but not rated
Read what inspectors found at Ashfield Nursing & Residential Home →
- September 2021Inspected but not ratedSafe: Inspected but not rated
- August 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2014
Report published without a new overall rating.
- May 2014
Report published without a new overall rating.
- March 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 8 December 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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