CQC report explained · a residential care home
What the CQC found at Ashford House Care 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
- People generally felt safe and medicines were managed safely. However, some risks, including malnutrition and a weakened immune system, were not fully reflected in risk assessments, and there were short periods when no staff were in the communal lounge.
- Effective?
- Requires improvement
- Staff had improved training and people had access to health professionals. However, staff did not always follow the conditions of a deprivation of liberty authorisation, and one person was not supported to eat until inspectors pointed this out.
- Caring?
- Requires improvement
- Staff had positive relationships with people and usually offered choices. However, staff were not always available to reassure a distressed person, and did not always record what caused distress or what support was provided.
- Responsive?
- Requires improvement
- Care plans covered people's physical, psychological, social and cultural needs, and relatives were involved in reviews. Activities had improved, but some people remained unoccupied and had limited opportunities to follow their interests and hobbies.
- Well-led?
- Requires improvement
- The manager was described as accessible and approachable, and some quality systems had been introduced. However, these systems did not identify or resolve all the concerns, including long-standing repairs and failures to follow deprivation of liberty conditions.
What inspectors found, January 2023
Rated Requires Improvement; the home improved from Inadequate and left Special Measures, but important safety, care and management improvements were still needed.
This was an unannounced follow-up inspection on 6 and 15 December 2022. Inspectors spoke with people, relatives and staff, observed care, and checked care, medicines, staff and management records.
The home had improved since the previous inspection. Medicines were managed safely, staff had received more training, safeguarding systems had improved, and environmental hazards had been addressed in some areas. People and relatives generally said staff were kind and that the manager was approachable.
However, some risks were not fully assessed. People sometimes waited for staff, activities were limited for some people, and staff did not always record information required by a deprivation of liberty authorisation. Repairs and improvements to the building had not been completed promptly, and the quality monitoring systems had not found all these problems.
The overall rating and all five question ratings were Requires Improvement. The home was no longer Inadequate or in Special Measures, but CQC still found a continuing breach of Regulation 17 about good governance.
Safer medicines
Medicines records were accurate, medicines were stored securely, and staff responsible for medicines had training and competency checks.
“Medicine administration records were up to date and accurate. Medicines were stored correctly and securely.” from the report
Improved safeguarding
Staff had safeguarding training and knew how to recognise and report suspected abuse. The previous breach relating to safeguarding had been resolved.
“All staff had received safeguarding training. They knew how to identify suspected abuse and how to report it.” from the report
Health support
Staff identified changes in people's health and contacted health professionals promptly when needed.
“Staff consulted healthcare professionals such as GP's, community nurses, speech and language therapists in a timely manner.” from the report
Approachable management
People, relatives and staff said the manager was accessible and that they felt supported.
“People, relatives and staff told us they were happy with the care and support provided.” from the report
Outstanding governance problems
seriousQuality checks had not found or resolved all the concerns. Repairs, decoration and replacement of some furniture and curtains were still outstanding, and the home remained in breach of Regulation 17.
“Quality assurance systems and processes had been introduced and had identified areas requiring improvement, they had failed to identify and/or address all the concerns found during this inspection.” from the report
Staff availability
needs fixingA last-minute absence made staff very busy. There were also short periods when no staff were available in the communal lounge, meaning people sometimes waited for help.
“There were short periods of time when there were no staff in the communal lounge to support people.” from the report
Incomplete risk information
needs fixingSome risk assessments did not fully identify risks relating to malnutrition or infection. The manager acted immediately on one missing risk assessment.
“Risk assessments for identifying risk of malnutrition had not been completed correctly and this meant potential risks could be missed.” from the report
Deprivation of liberty records
seriousStaff did not routinely record information required by one person's authorisation. This meant information needed to support the least restrictive care was not always available.
“Staff were not routinely recording this information and therefore did not always comply with the conditions.” from the report
Limited activities
minorAlthough activities had improved, some people were unoccupied for much of the time and had limited chances to follow their interests and hobbies.
“However, some people were unoccupied for the majority of the time and had limited opportunities to follow their interests and hobbies.” from the report
- 01What is the current timetable for repairing the rotting window frames and completing the outstanding decoration and replacements?
- 02How will you check that all malnutrition, infection and other risk assessments are complete and updated when people's needs change?
- 03How do staff record and review what happens when a person becomes distressed or resists care, including the conditions of any deprivation of liberty authorisation?
- 04How will you ensure there are enough familiar staff available when someone is absent at short notice?
- 05What regular activities are available for each person based on their interests, hobbies and cultural preferences?
This was an unannounced follow-up inspection covering all five key questions, with infection prevention and control also checked as part of the Safe question. This explanation was written from the published report of 24 January 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, August 2022
Rated Inadequate and in special measures; inspectors found serious repeated failings in safety, consent, staff training and management.
This was an unannounced focused inspection on 7 and 14 March 2022. Inspectors spoke with people, relatives and staff, observed care, and checked care records, medicines records, staff files and management systems. They also checked infection prevention and control.
The home remained Inadequate overall. Safe, effective and well-led were all rated Inadequate. Risks were not always assessed or updated, medicines records had gaps, and environmental hazards were not dealt with quickly. Many staff had not completed training needed for the people they supported.
The home had improved infection control and recruitment checks. People and relatives spoke positively about the food, staffing and visits. Staff were seen to be kind and caring, but people had few activities and said they were bored. A new manager had started making changes, but inspectors could not see that these changes were established or lasting.
Kind interactions
Inspectors saw staff respond promptly when people were distressed and support them in a calming way. Staff knew people's likes, dislikes and care preferences.
“We observed kind and caring interactions.” from the report
Enough staff
Inspectors found there were enough staff to meet people's needs. A dependency tool had been introduced to help plan staffing.
“The service was overstaffed, and we found there were enough staff employed to meet people's needs.” from the report
Infection control improvements
The home was no longer in breach for infection prevention and control. Inspectors were assured that visitors, protective equipment and infection outbreak arrangements were being managed.
“Enough improvement had been made at this inspection with regard to infection prevention and control” from the report
Unsafe medicines systems
seriousThere were several gaps in medicines administration records, so inspectors could not be sure people received medicines as prescribed. There were also risks linked to pain-relief patches and contradictory instructions.
“This meant we could not be assured people received their medicines as prescribed.” from the report
Risks and hazards
seriousGarden hazards and unlocked areas could put people at risk of harm or injury. Some people's care plans and risk assessments were not updated after falls or changes in health.
“People's risk assessments and care plans were not always reviewed after they had fallen, or their needs changed.” from the report
Incomplete staff training
seriousStaff had not completed many training programmes relevant to people's needs. New staff did not receive the home's training before providing care.
“None of the staff had undertaken 15 of the provider's training programmes including diabetes, bedrail use and safety, continence awareness, epilepsy awareness, falls safety awareness, pressure sore prevention and sepsis.” from the report
Weak management checks
seriousThe home's quality systems did not identify or address important problems. This was the third inspection where breaches of regulations were found.
“This is the third inspection where breaches of regulation have been identified.” from the report
- 01What checks now show that every person's medicines are being given and recorded correctly?
- 02Have all people's risk assessments and care plans been reviewed after falls or changes in health?
- 03Which staff have now completed safeguarding, Mental Capacity Act, dementia, epilepsy and diabetes training?
- 04How are mental capacity assessments and best-interest decisions being completed, reviewed and discussed with relatives or attorneys?
- 05What regular activities are now available for people who previously said they were bored?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their ratings were not given in this report. This explanation was written from the published report of 9 August 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 Ashford House Care Home
7 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- January 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2022Inadequatestayed InadequateSafe: InadequateEffective: InadequateWell-led: Inadequate
- November 2021Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementWell-led: Inadequate
- April 2021Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2017Goodstayed GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- June 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2020
Registered with the Care Quality Commission on 1 January 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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