CQC report explained · a nursing home
What the CQC found at Ashlar House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from avoidable harm. Inspectors found enough staff, safe medicines procedures, suitable risk assessments, infection control measures and systems for learning from incidents.
- Effective?
- Good
- This key question was not inspected during this visit. Its rating was carried over from the previous inspection.
- Caring?
- Good
- This key question was not inspected during this visit. Its rating was carried over from the previous inspection.
- Responsive?
- Good
- This key question was not inspected during this visit. Its rating was carried over from the previous inspection.
- Well-led?
- Good
- Inspectors found effective audits, regular meetings and supervision, and a manager who listened to people, relatives and staff and worked with health professionals.
What inspectors found, November 2023
Rated Good; inspectors found safe, well-managed care, with minor improvements needed to recruitment files.
This was an unannounced, focused inspection. Inspectors visited on 8 November 2023 and reviewed Safe and Well-led. They spoke with people living there, relatives, staff and health professionals, and checked care, medicines, recruitment and other records.
The home was rated Good overall, with Good ratings for Safe and Well-led. Inspectors found enough trained staff, safe medicines systems, suitable risk assessments and effective infection control. People and relatives said they felt safe and spoke positively about the care.
The main shortfall was in staff recruitment records. Some files did not contain proof of address, so inspectors made a recommendation to improve these records. The Good rating was unchanged from the previous inspection, published in May 2018, but the other key questions were not inspected in this visit.
Enough trained staff
Staff numbers and skills matched people's needs. Staff received induction, training and shadowing before working independently.
“The numbers and skills of staff matched the needs of people using the service.” from the report
Safe medicines
Medicines were given as prescribed and recorded. Staff had training and competency checks, and medicines were stored securely.
“People were given their medicines safely and as prescribed, and it was recorded on their medicine administration record.” from the report
People felt safe
People and relatives told inspectors they felt safe. Staff understood safeguarding and knew how to report concerns.
“People using the service and their relatives told us they felt safe.” from the report
Open management
The home used meetings, surveys, audits and supervision to hear views and make improvements. Relatives and staff described management as approachable and supportive.
“The service used this information to implement action plans and make improvements.” from the report
Good infection control
Inspectors found the environment clean, with suitable supplies of protective equipment and regular infection-control checks.
“The environment was clean, and people confirmed regular cleaning took place.” from the report
Recruitment records
needs fixingSome staff recruitment files were missing proof of address. Inspectors recommended that recruitment checks and documents should be managed more consistently.
“Minor improvements were needed to staff recruitment files to ensure they meet the regulations.” from the report
- 01Have all staff recruitment files now been updated to include proof of address and the other required documents?
- 02How do you check that staff are safe to work with people before they start?
- 03How many staff are on duty on each shift, and how do their skills match the needs of people living here?
- 04How are medicines given, checked and audited, including medicines given when needed?
- 05What ratings did the previous inspection give for Effective, Caring and Responsive?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried over from the previous inspection. This explanation was written from the published report of 22 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, June 2018
Rated Good; inspectors found caring, personalised support and improvements since the previous inspection, but some risk and behaviour records needed attention.
This was an unannounced comprehensive inspection on 9 and 11 May 2018. Inspectors observed care, spoke with people, relatives, staff and healthcare professionals, and checked care records, medicines, staffing, training, maintenance and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff overall, safe medicines management, suitable training, good healthcare support, kind interactions and activities that matched people's interests.
The home had improved since March 2017, when it was rated Requires Improvement and breached a staffing regulation. Staffing levels had improved and the earlier concerns about refresher training, appraisals and activities had been addressed.
Inspectors still found some issues. These included a potential trip hazard, one unsafe manual handling move, variable mental capacity records, weaknesses in some mental health assessments and limited staff training on distressed behaviour. The provider acted promptly on the issues raised.
Improved staffing
Staffing levels had improved since the previous inspection and inspectors found people's needs were met in a timely manner.
“Staffing levels had improved since our last inspection and people's needs were now met in a timely manner.” from the report
Kind and respectful care
Inspectors saw warm, positive interactions. Staff offered choices, knew people's preferences and protected their privacy and dignity.
“Staff treated people with dignity and respect and demonstrated positive values such as calling people by their preferred names” from the report
Personalised support
Care plans recorded people's histories, likes, dislikes and routines. Staff used this information to provide care in the way people wanted.
“People's care plans included information about their life history, likes, dislikes, routines, preferences and family tree.” from the report
Activities had improved
People had activity plans and a wider range of activities, entertainment and community opportunities than at the previous inspection.
“People were provided with activities and entertainment of their choosing and regularly accessed activities within the community.” from the report
Quality improvement
The provider used audits and reviews to identify shortfalls and showed inspectors evidence of action taken.
“The service had a robust quality assurance system and identified shortfalls were addressed.” from the report
Trip hazard
needs fixingOne person's door was held open with a cushion that they walked over. Inspectors said this could cause a trip, and the provider updated the risk assessment afterwards.
“The person had their door wedged open with a cushion, which they walked over as they went in and out of room.” from the report
Moving and handling
needs fixingInspectors observed one inappropriate manual handling move by two staff members. Further training was booked and practice was to be monitored.
“During this inspection, we did observe one inappropriate manual handling move by two members of staff, which we discussed immediately with the operations manager.” from the report
Behaviour support
needs fixingThree staff told inspectors they had not received training in managing challenging behaviour. One care plan lacked enough detail about triggers and how to reduce distress.
“We spoke with three staff who told us they had not received any training in how to manage challenging behaviour.” from the report
Mental health assessments
needs fixingSome assessment tools were not applied accurately. The report gave an example where a record did not match information that the person often expressed suicidal thoughts.
“We found the assessment tools were not always well applied as the results did not always accurately reflect the person.” from the report
Manager registration
minorThere was no registered manager at the time of the inspection. The operations manager was applying to register, while recruitment for a suitable manager continued.
“The operations manager for the provider was currently in the process of completing their application to register as the manager.” from the report
- 01What training have all staff now completed on supporting people whose behaviour becomes distressed or agitated?
- 02How are behaviour care plans kept up to date with each person's triggers and calming techniques?
- 03How do you check that mental health assessments accurately reflect a person's current wellbeing and risks?
- 04What changes were made to prevent doors, cushions or other items becoming trip hazards?
- 05Who is currently responsible for managing the home, and what is the progress of the manager registration application?
This was an unannounced comprehensive inspection covering the premises, care provided and all five CQC question areas. This explanation was written from the published report of 13 June 2018 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 Ashlar House
4 rated inspections over 8 years: the service has held its Good rating throughout.
- November 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- April 2017Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- August 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 15 February 2011.
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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