CQC report explained · a residential care home
What the CQC found at Ashill Lodge Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, June 2023
Rated Requires Improvement; inspectors found avoidable safety risks, medicines concerns and weak oversight, with breaches of two regulations.
This was an unannounced focused inspection of Safe and Well-led. Three inspectors, including a medicines inspector, visited on 14 December 2022. They observed care and mealtimes, spoke with people, relatives, staff and a health professional, and checked medicines, care plans and other records.
The home was not always safe. Inspectors found unguarded stairs, unattended hot teapots, an unlocked laundry room containing chemicals and a stiff fire door. They also found medicines were not always managed robustly, including concerns about night-time cover, creams, controlled drugs and guidance for medicines given when needed.
Staff were often kind, and many relatives spoke positively about the care. However, people were not always supervised safely or supported in a person-centred way. Staffing was much lower at night, and some care records and risk assessments were contradictory.
The home was rated Requires Improvement overall, and also Requires Improvement for Safe and Well-led. These ratings had not improved since the previous inspection. The provider was in breach of Regulation 12 and Regulation 17, and received a warning notice for Regulation 17.
Kind staff
Inspectors saw staff being kind and caring. Most relatives also gave positive feedback about their family member's care.
“Through our observations we noted staff were kind and caring, however not always responsive to people's individual needs.” from the report
Clean environment
The home was clean despite some domestic staff sickness. Relatives also praised its cleanliness.
“Despite some domestic staff sickness, the home was clean and there were regular cleaning schedules followed by staff to ensure high standards of cleanliness were maintained across the home.” from the report
Health care partnership
A health care professional described the working relationship as positive and said the home responded proactively to people's needs.
“The health care professional spoken with expressed their satisfaction and said there was good partnership working and the service was proactive.” from the report
Safeguarding response
Staff had safeguarding training, and the provider raised a concern without delay after inspectors shared relatives' concerns.
“They responded by raising a safeguarding concern without delay.” from the report
Medicines management
seriousThere were repeated concerns about medicines. Staff cover and training at night, guidance for medicines given when needed, storage of creams and controlled drugs, and reporting errors were not robust enough.
“At our most recent inspection we found people received their medicines safely most of the time, however, there was still an issue about having sufficient numbers of staff trained to give medicines at night if required and continued concerns about the management of medicines” from the report
Night staffing
seriousStaff numbers were significantly lower at night. Inspectors were concerned that two staff might be needed to help one person, leaving no staff to monitor others.
“We however had concerns that should there be an incident or anyone required additional support how 2 members of staff could effectively assist.” from the report
Weak management checks
seriousAudits did not identify the risks inspectors found, and oversight did not ensure safe, person-centred care. This led to a breach of Regulation 17 and a warning notice.
“We found oversight and governance was not sufficiently robust and did not ensure people received the regulated activity in a safe and person-centred way.” from the report
Limited person-centred support
needs fixingPeople were not always offered meaningful choices or supported to communicate in ways suited to them. Staff were not always visible or available when people needed supervision.
“During our observations we noted peoples choices were not always promoted in a way that demonstrated that staff used different communication methods appropriate to people's needs” from the report
- 01What has been done to prevent people accessing the stairs without the supervision stated in their risk assessments?
- 02How are medicines given when needed, creams and controlled drugs now stored and checked?
- 03How many staff are on duty overnight, and what happens if two staff are needed to help one person?
- 04How are fire doors, chemicals, hot drinks and other environmental risks checked each day?
- 05How will you show that audits now identify people's safety risks and their individual communication and choice needs?
This was a focused inspection of Safe and Well-led; Effective, Caring and Responsive were not rated, while infection prevention and control was considered within Safe. This explanation was written from the published report of 20 June 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, March 2019
Ashill Lodge Care Home was rated Requires Improvement; inspectors found kind care, but medicines, records, activities and management needed further work.
The inspection was unannounced and took place on 22 January 2019. Inspectors spoke with people living at the home, visitors, relatives and staff. They observed care and checked care plans, staff files, medicines records and quality checks.
The home had improved since the previous inspection, including changes to the building, staff support and care planning. People and relatives spoke positively about the kindness of staff. However, some improvements were new and were not yet firmly established.
Inspectors found unsafe medicine recording and administration systems. Care records did not always give staff clear, up-to-date guidance. Staff training and checks on service quality also needed to improve. There were not enough planned activities for people during the day.
The overall rating was Requires Improvement. Caring was rated Good. Safe, Effective, Responsive and Well-led were all rated Requires Improvement. The home had one repeated breach, relating to safe care and treatment and medicines.
Kind and respectful staff
People and relatives gave positive feedback about staff. Inspectors saw staff supporting people with compassion, dignity and humour.
“Staff were observed treating people with compassion and dignity.” from the report
People had choices
People were supported to choose their routines, where they spent time and how they received care. Staff supported independence where this was safe.
“People were involved in day to day decisions about their care and had choices about their preferred routines.” from the report
Improving leadership
The new manager had built better relationships with people, relatives and staff. Staff reported improved morale and felt more supported.
“The new manager was making good progress and has made some changes to the service delivery.” from the report
Clean and maintained home
Inspectors found the home clean and well maintained. Fire safety, equipment checks and routine servicing records were in order.
“We found the service was clean with daily records showing what tasks were undertaken which included deep cleaning of the service.” from the report
Medicine safety
seriousMedicine records contained gaps and errors. Inspectors could not be assured that medicines were always stored, recorded and given safely.
“The issues we identified meant we were not assured people always received their medicines safely and as intended.” from the report
Care records
needs fixingSome care plans did not clearly describe people's needs, risks or the support staff should provide. This could make care less consistent.
“Care plans were not all up to date and not used by staff to inform the care they should be providing.” from the report
Too few activities
needs fixingThere was no clear person responsible for planning activities. People were not offered enough regular opportunities based on their interests.
“People were not sufficiently occupied throughout the day and did not have sufficient opportunity to be.” from the report
Training and health knowledge
needs fixingThe manager could not yet show that all staff were competent. Some staff lacked training and knowledge about people's health needs.
“The manager was not yet able to demonstrate that all the staff had the necessary competencies.” from the report
Quality checks
needs fixingAudits and records did not always identify problems or show what action had been taken. The new quality lead had only recently started.
“The quality assurance systems were not yet fully developed and could not clearly demonstrate how they improved the service based on feedback from people.” from the report
- 01What changes have you made to medicine records, including controlled drugs, skin patches and fridge temperature checks?
- 02How do you check that every member of staff is competent and has completed the training needed for people's health conditions?
- 03How will you keep care plans up to date and make sure staff use them during each shift?
- 04Who is responsible for planning activities, and what regular activities are now available for each person's interests?
- 05How do your audits identify problems and show that action has been completed?
This was an unannounced comprehensive inspection covering all five CQC questions and the overall rating, with improvements compared with the previous inspection on 12 and 14 December 2017. This explanation was written from the published report of 22 March 2019 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 Ashill Lodge Care Home
3 rated inspections over 5 years: the service has held its Requires improvement rating throughout.
- June 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2019Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- March 2018Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2017
Registered with the Care Quality Commission on 6 February 2017.
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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