CQC report explained · a residential care home
What the CQC found at Ashleigh House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicines were not always stored, administered or managed safely. Some fire risks, visiting professionals' vaccination records and recruitment checks were also incomplete, although the provider took immediate action.
- Effective?
- Good
- This question was not inspected or rated in this report.
- Caring?
- Good
- This question was not inspected or rated in this report. People told inspectors staff were kind and caring.
- Responsive?
- Good
- This question was not inspected or rated in this report. Care plans did not always reflect people's choices and preferences.
- Well-led?
- Requires improvement
- Care plans did not fully reflect people's arrangements and choices, and the provider's checks did not identify all the problems found. The provider took action to improve records and quality checks.
What inspectors found, March 2022
Ashleigh House rated Requires Improvement; inspectors found kind care, but medicines, risk checks and care records were not always safe or reliable.
This was a targeted inspection about infection prevention and control during the COVID-19 pandemic. Inspectors found some concerns and widened the inspection to look at Safe and Well-led. They visited on 20 and 27 January 2022, spoke with people, staff, managers and health professionals, and checked care records and other documents.
The home was not always safe. Medicines were not always stored or administered with clear instructions. Some fire risks had not been fully assessed, records of visiting professionals' vaccination status were incomplete, and one recruitment file was missing information. The provider took immediate action on these issues.
The home was not always well-led. Care plans did not fully record people's choices, including arrangements for sharing a room and support with personal care. The provider updated care plans and put other improvements in place, but its own checks had not identified all the problems.
The overall rating changed from Good at the previous inspection to Requires Improvement. This means inspectors found some aspects of care were not always safe or consistently managed, with limited assurance about safety.
Kind and caring staff
People were happy with the care and support they received. Inspectors also received positive feedback from health and social care professionals.
“People were happy with the care and support they received, and they told us staff were kind and caring.” from the report
Clean home and visiting controls
The home was clean and hygienic. Visitors were asked to test for COVID-19, use protective equipment and follow hand hygiene procedures.
“There were systems in place to ensure high standards of cleanliness were kept and the home was clean and hygienic when we visited.” from the report
Working with other professionals
The home worked with care coordinators, nurses, GPs and psychiatrists to meet people's health and social care needs.
“The service worked in partnership with a range of health and social care professionals including care coordinators, district nurses, GPs and psychiatrists” from the report
Medicine safety
seriousInstructions were missing for one medicine that was prescribed for use when needed. Medicine storage temperatures were not recorded, and staff competency checks had not been completed in line with best practice.
“People's medicines were not always stored, administered, and managed safely.” from the report
Incomplete fire risk checks
seriousTwo people who smoked had an increased risk of harm from fire, but this had not been identified in their risk assessments. The provider assessed and acted on this during the inspection.
“The risk of harm from fire had not been fully assessed as we identified two people who were at increased risk of harm from fire due to smoking however this risk had not been identified.” from the report
Care plans did not reflect choices
needs fixingCare plans did not fully record people's accommodation arrangements or preferences for personal care. Two people sharing a room had not been fully consulted about the arrangement.
“Care plans did not fully reflect people's care and accommodation arrangements and choices.” from the report
Quality checks missed problems
needs fixingThe provider had audits and checks, but these did not identify all the issues later found by inspectors. The provider was asked to continue developing its quality assurance processes.
“Although the provider's own audits and checks did not identify all the issues we found, the provider has taken immediate action to resolve the shortfalls we identified” from the report
Vaccination records
needs fixingThe home did not always keep records showing the vaccination status of eligible visiting professionals. The provider updated its procedure during the inspection.
“At the time of the inspection we found the service did not have effective measures in place to ensure this requirement was being met” from the report
- 01What evidence can you show that medicines are now stored at the correct temperature and that temperatures are recorded?
- 02How are staff now given clear instructions for medicines prescribed to be given when needed, and how is their competency checked?
- 03How have fire risks for people who smoke been assessed and reduced?
- 04How are residents consulted about room-sharing and how is their privacy and dignity protected?
- 05What new quality checks are being used to make sure care plans and risk assessments remain complete and accurate?
This began as a targeted infection prevention and control inspection and was widened to Safe and Well-led; the other three question ratings were not given in this report. This explanation was written from the published report of 30 March 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, April 2021
Ashleigh House was inspected but not rated; inspectors found good infection control, but some vulnerable staff lacked risk assessments.
This was an announced, targeted inspection on 17 March 2021. It checked how well the home was prepared to prevent and control COVID-19 infections.
Inspectors were assured that visitors were managed safely, staff used personal protective equipment, testing was available, and the home was clean, well ventilated and safely arranged. People were supported to see relatives safely, or to keep in touch by phone or video call.
The inspectors found one gap. Staff who were more vulnerable to COVID-19 did not have individual risk assessments in place. The provider said these would be completed as soon as practicable.
The home was inspected but not rated. This report does not provide a full rating for the five areas of care.
Infection control
The home had measures covering visitors, PPE, testing, ventilation, hygiene and the management of outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Safe family contact
People could see visitors in the conservatory when this was safe. When visits were not possible, the home supported phone and video contact.
“When this was not possible, people were supported to speak to their families on the phone or via video call.” from the report
Visitor arrangements
Visitors received information and instructions, and staff followed social distancing guidance.
“Information and instructions for visitors were displayed and explained in person by the receptionist.” from the report
Missing staff risk assessments
needs fixingStaff who were more vulnerable to COVID-19 did not have risk assessments in place. The provider said it would complete them as soon as practicable.
“The provider had not ensured staff who were more vulnerable to COVID-19 had a risk assessment in place.” from the report
- 01Have risk assessments now been completed for staff who are more vulnerable to COVID-19?
- 02How are visitors currently screened and supported to avoid spreading infection?
- 03How does the home arrange testing for people living here and for staff?
- 04What happens if someone develops COVID-19, including the use of isolation rooms?
- 05How can residents keep in touch with relatives if an in-person visit is not safe?
This was a targeted inspection of infection prevention and control during the coronavirus pandemic; it did not provide ratings for the other care areas. This explanation was written from the published report of 28 April 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 House
3 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- March 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2021Inspected but not ratedSafe: Inspected but not rated
- March 2018Goodstayed GoodSafe: GoodWell-led: Good
- March 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 3 December 2010.
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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