CQC report explained · a residential care home
What the CQC found at Ashleigh Court Rest 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
- Inspectors found unsafe medicine storage, including an expired medicine and a partly unlocked medicine trolley. Risk assessments, staffing, safeguarding and infection control were otherwise described positively.
- Effective?
- Good
- People's needs and choices were assessed and reviewed. Staff were trained, consent arrangements had improved, meals met people's preferences, and people were supported to access healthcare.
- Caring?
- Good
- Staff were described as kind and caring and knew people well. People were involved in decisions and supported with dignity, privacy and independence.
- Responsive?
- Good
- Care plans were personalised, accurate and regularly reviewed. People had choice and control, took part in activities, maintained relationships and could raise complaints.
- Well-led?
- Requires improvement
- The new management structure had led to improvements, but governance systems still failed to identify medicine problems and out-of-date risk assessments. The provider remained in breach of Regulation 17.
What inspectors found, June 2022
Ashleigh Court Rest Home is rated Requires Improvement; inspectors found kind, personalised care but unsafe medicine storage and weak oversight.
Inspectors made an unannounced visit on 28 April 2022. They spoke with people living in the home, relatives and staff. They also observed care and checked care plans, risk assessments, medicines, staff records and management records.
People said they felt safe and were treated kindly. Inspectors found good support with consent, meals, healthcare, personal choices, activities and relationships. Care plans had improved and complaints had been handled appropriately.
There were still important problems with medicines. An expired medicine was stored in the home, a medicine trolley was left partly unlocked, and some instructions for medicines given when needed were not detailed enough.
The home remained in breach of Regulation 17 on good governance. Its audits had not found the medicine problems, and some task-specific risk assessments had not been reviewed since July 2019. The overall rating stayed Requires Improvement, although Effective, Caring and Responsive improved to Good.
Kind and respectful care
People and relatives spoke positively about the staff. Inspectors saw that people were treated with dignity and supported to remain as independent as possible.
“People were cared for by kind and caring staff who knew people well and supported them to be individuals and ensured there was time to spend with people.” from the report
Personalised care plans
Care plans had improved since the previous inspection. They contained accurate information about people's needs and were reviewed regularly.
“This inspection found all key information regarding people's needs was consistently included in their care plans.” from the report
Improved consent practice
The home had improved how it followed the Mental Capacity Act. Best-interest decisions were recorded and restrictions had the appropriate authorisations.
“During this inspection we found detailed records of discussions and decisions made in people's best interests.” from the report
Choice, activities and family contact
People were supported to choose their routines, meals and activities. The home also helped people maintain family relationships and access the community.
“People were encouraged to engage in activities both in the home and in the community.” from the report
Medicine storage
seriousAn as-needed medicine was stored after its expiry date. A medicine trolley was also left partly unlocked while unattended.
“We found an 'as and when required' medicine was being stored past its expiry date.” from the report
Incomplete medicine instructions
seriousInstructions for some as-needed medicines did not clearly explain when or how often they should be given. Staff knew how to use them, but the records were not sufficient.
“Protocol records for 'as and when required' medicines were not sufficiently detailed to inform staff when these medicines should be administered.” from the report
Weak management checks
seriousAudits did not identify the medicine problems. Some task-specific risk assessments had not been reviewed since July 2019.
“The providers medicine audits failed to identify an 'as and when required' medicine had expired and had not been returned to the pharmacy.” from the report
- 01How have you ensured that expired medicines are removed and returned to the pharmacy promptly?
- 02How are medicine trolleys kept locked whenever they are unattended?
- 03What changes have you made to the instructions for as-needed medicines, and how do you check that staff follow them?
- 04Have all task-specific risk assessments now been reviewed and updated, including those for staff safety, visitors, cleaning equipment and maintenance?
- 05What action plan did you send to CQC, and what evidence can you show of progress since this inspection?
This was an unannounced follow-up inspection checking the previous action plan, with an additional thematic probe about oral healthcare; all five key questions were rated. This explanation was written from the published report of 23 June 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.
What inspectors found, May 2021
Rated Requires Improvement; inspectors found enough staff and some safe care, but people’s rights, personalised care and quality checks were not reliable.
The inspection was unannounced and took place on 25 February 2021. Two inspectors spoke with people, relatives, staff and managers. They reviewed care records, medicines records, training information and quality checks.
The home had enough staff and medicines were generally given safely. Infection control had improved, and people could access healthcare. However, some risk information was conflicting, staff did not always know the guidance for medicines given when needed, and some training was out of date.
Inspectors found that people were not always involved in decisions made for them. Care was not consistently personal, and staff missed opportunities to talk with people beyond completing tasks. Records and management checks did not reliably identify or fix these problems.
The overall rating and all five question ratings were Requires Improvement. This was the home’s third consecutive Requires Improvement rating. The previous breaches relating to the environment had been resolved, but the home remained in breach of regulations about people’s rights, personalised care and governance.
Enough staff
Inspectors saw enough staff to support people safely. People said staff came quickly when they used the buzzer.
“We saw there were enough staff to support people. Staff were visible in communal areas.” from the report
Improved infection control
The home had taken action to improve infection control and inspectors were assured about its arrangements for preventing and managing outbreaks.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Healthcare access
People said they could access health appointments and that staff would seek medical help if they became unwell.
“People told us they had access to regular health appointments; including receiving home visits from the optician and dentist.” from the report
Privacy and independence
Staff knocked before entering rooms, used people’s preferred names and encouraged people to do things independently where they could.
“People's privacy was respected, and we saw staff knocking on people's doors before entering their room.” from the report
Unclear safety information
needs fixingSome care records gave conflicting information about a person’s mobility and the support they needed. This could make it harder for staff to provide consistent safe care.
“This meant staff did not consistently have access to accurate information on the risks to people's safety.” from the report
Medicines guidance
needs fixingStaff did not know where to find or how to follow guidance for medicines given when needed. Records of temperatures for medicines in the medicines trolley could not be located.
“This meant there was a risk that the guidance in place would not be followed as staff were not aware of this.” from the report
People’s rights
seriousThe home made applications to restrict everyone’s liberty, including some people who had capacity. For people who lacked capacity, there was no evidence that decisions were made in their best interests and in the least restrictive way.
“For people who lacked capacity, the MCA and its code of practice had not been followed.” from the report
Limited personal interaction
needs fixingStaff interactions were mainly linked to care tasks. Inspectors saw missed opportunities for conversation and meaningful engagement.
“Our observations throughout the day showed that staff interactions with people was mainly limited to when care tasks were being completed and there were missed opportunities for meaningful engagement with people.” from the report
Out-of-date care plans
needs fixingSome care plans were not reviewed regularly and contained inaccurate information. This meant they might not reflect people’s current needs and preferences.
“Some care plans had not been reviewed regularly. One person's record had not been updated since 2019.” from the report
Weak quality checks
seriousThe home’s audits did not identify several problems found during the inspection. The provider had also not acted effectively on known training gaps.
“These systems had not identified the areas for improvement found at this inspection.” from the report
- 01How are you making sure every person’s capacity is assessed correctly and that best-interest decisions are recorded?
- 02How do staff find and follow the guidance for medicines given on an 'as and when required' basis?
- 03How often will my relative’s care plan be reviewed, and how will you check that information about mobility and preferences is accurate?
- 04What training was overdue at the inspection, and has all of it now been completed?
- 05How do your audits identify problems with care records, medicines and people’s choice and control?
This was an unannounced inspection covering all five CQC key questions, with particular attention to risks linked to a serious injury notification and infection prevention and control. This explanation was written from the published report of 8 May 2021 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 Ashleigh Court Rest Home
5 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- June 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2021Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- May 2021Requires improvementstayed Requires improvementSafe: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2016
Registered with the Care Quality Commission on 26 May 2016.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
At least 100 live-in carers within about an hour of Birmingham
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £950 to £1,230 a week. 79 can care for a couple. 9 years' experience on average.
“God doesn't make people like her anymore!”
“I have never met a person who is so kind and thinks about others before himself to such an extent as Chris Malagala.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.