CQC report explained · a nursing home
What the CQC found at Ashgrove Nursing 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 did not always receive medicines as prescribed. Medicine records had gaps, one medicine was out of stock for five days, and some instructions were unclear. Environmental damage and worn furniture or equipment also raised infection control concerns.
- Effective?
- Good
- People's needs were assessed and reviewed. Staff had relevant training, supported eating and drinking, worked with health professionals and followed the principles of the Mental Capacity Act.
- Caring?
- Good
- People were treated with kindness and compassion. Staff knew people well, respected privacy, involved people in decisions and encouraged independence.
- Responsive?
- Good
- Care was adapted when people's needs changed. Staff understood people's preferences and communication needs, supported activities and had a system for handling complaints.
- Well-led?
- Requires improvement
- Medicine audits did not identify the problems found by inspectors. Other quality checks were effective, and the management team took immediate action after the inspection.
What inspectors found, August 2023
Rated Requires Improvement; inspectors found kind, responsive care, but medicines were not always given safely and management checks missed this.
This was an unannounced inspection on 27 June 2023. One inspector, a specialist nurse adviser and an Expert by Experience visited the home. They spoke with people, relatives, staff and visiting professionals, observed care, and checked care records, medicine records, staff recruitment files and quality checks.
People generally felt safe and were treated with kindness. Staff understood people's needs, supported eating and drinking, worked with health professionals, respected people's choices and provided activities. Inspectors rated Effective, Caring and Responsive as Good.
The main concern was medicines. Records had gaps, staff could not always confirm whether medicines had been given, and some people did not receive medicines consistently. The home also had environmental issues that could affect infection control. Checks on medicines had not found these problems, so Safe and Well-led were rated Requires Improvement.
This was the first inspection of the newly registered service. The previous rating, under a previous provider, was Good and was published on 24 March 2022. The provider must send an action plan, and the CQC said it would monitor progress with the provider and local authority.
Kind and respectful care
Staff knew people well, respected their privacy and supported them to make choices and remain as independent as possible.
“People were treated with kindness and compassion by a staff team who knew them well.” from the report
Good support with health
Staff understood people's dietary needs and worked with healthcare professionals when people's health changed.
“Staff worked with healthcare professionals to ensure people's health needs were met.” from the report
Activities and communication
People were offered group and one-to-one activities. The home used pictorial communication, visual aids and British Sign Language support.
“People were supported with a combination of group and one to one activities which helped to reduce social isolation and promote their wellbeing.” from the report
Safe recruitment
The provider completed pre-employment checks, including checks through the Disclosure and Barring Service.
“Staff were safely recruited. The provider had carried out pre-employment checks, including DBS checks, to ensure staff were safe to work with people.” from the report
Medicines were not consistently managed
seriousThere were gaps in medicine administration records and staff could not always confirm whether medicines had been given. One person's medicine was out of stock for five days, and another person missed 11 doses of dementia medicine.
“People did not always receive their medicines as prescribed. There were gaps in medicine administration records and staff were unable to confirm if people had received their medicines.” from the report
Environmental infection risks
needs fixingSome damage, worn furniture and worn equipment could not be cleaned in line with infection control guidance. Refurbishment and an improvement plan were underway.
“These included some damage to the home environment, worn furniture or equipment which could not be cleaned in accordance with infection control guidance.” from the report
Medicine checks missed problems
seriousThe home's medicine audits had not identified the issues found during the inspection. This contributed to the Requires Improvement rating for Well-led.
“Medicines audits had not identified the concerns we found during the inspection.” from the report
- 01How have you checked that every person's medicines are now being given and recorded correctly?
- 02What is the process when a medicine is missed, out of stock or cannot be given at the planned time?
- 03Has the refurbishment and infection control improvement plan been completed, and which environmental issues remain?
- 04How often are medicine records audited now, and who checks that problems are acted on?
- 05What progress has been made since the new manager started and since the CQC action plan was requested?
This was an unannounced full inspection of the care home, including care and the premises, with all five key questions assessed; it was the first inspection of the newly registered service. This explanation was written from the published report of 24 August 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.
Every inspection of Ashgrove Nursing Home
5 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- August 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2022Inspected but not ratedSafe: Inspected but not rated
- August 2020Inspected but not ratedSafe: Inspected but not rated
- August 2019Goodstayed GoodSafe: Requires improvementWell-led: Good
- July 2018Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- November 2022
Registered with the Care Quality Commission on 11 November 2022.
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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