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?
- Good
- People were protected from abuse and avoidable harm. Staffing, recruitment, medicines and safeguarding systems had improved, although infection risk assessments about staff and people moving between settings needed more detail.
- Effective?
- Requires improvement
- People had more choice over food and received better support, healthcare and consent processes. However, staff sometimes used snacks to manage behaviour, some people were gaining weight, and recognised Positive Behaviour Support and autism training had not yet taken place.
- Caring?
- Good
- Staff treated people with kindness, dignity and respect. People were supported to make choices, communicate their views and take more control of their daily lives.
- Responsive?
- Requires improvement
- Care plans and daily routines were more personalised. However, meaningful activities and community links were still developing, concerns were not always recorded as formal complaints, and people's advance wishes had not yet been fully documented.
- Well-led?
- Requires improvement
- The new registered manager had brought more open, person-centred leadership and better communication. The provider's own checks did not reliably identify known shortfalls, and independent oversight and governance systems needed further development.
What inspectors found, July 2021
Rated Requires Improvement; care was safer and kinder, but inspectors found ongoing weaknesses in support, activities and management oversight.
This was an unannounced inspection on 18 May 2021. Inspectors spoke with people, staff, relatives and other professionals. They observed care and checked care plans, medicines, recruitment, training, incidents, complaints and management records.
The home had improved significantly since its previous Inadequate rating. Staffing had increased, care was more personal, and people had more choice, independence and respectful support. The home was no longer breaching regulations and had left special measures.
Safe and Caring were rated Good. Effective, Responsive and Well-led were rated Requires Improvement. This means the home had made progress, but some aspects of people's care and the way the home was managed were still inconsistent.
Improved staffing
Staffing levels had increased substantially. Inspectors found enough staff to support people safely, provide one-to-one support and enable more activities.
“Staffing levels were now sufficient to support people in a safe and person-centred way.” from the report
Safer care
Safeguarding systems, risk management, recruitment checks and medicines processes had improved. People received their medicines as prescribed.
“There were now appropriate systems in place to protect people from the risk of abuse.” from the report
Kind and respectful support
Staff supported people calmly and respectfully. They promoted privacy, dignity, independence and involvement in everyday decisions.
“Staff now treated people in a caring and respectful way that promoted their Human Rights.” from the report
More personalised routines
People were supported as individuals rather than being expected to follow one shared timetable. Their daily routines better reflected their preferences.
“People now received a more personalised approach to care and had new daily routines that better reflected their needs and interests.” from the report
Better communication
Staff used pictorial aids, simple Makaton signs and other tools to help people express choices. Some people's communication had improved.
“We observed that staff were more confident in communicating with people according to their individual needs.” from the report
Healthy eating and behaviour support
needs fixingStaff were often seen using snacks to distract people or manage behaviour. Some relatives were concerned about weight gain, and specialist training was still outstanding.
“People had greater choice and control over their meals, but further action was needed to ensure people were supported to achieve a healthier diet.” from the report
Activities and community life
needs fixingThe pandemic had restricted outside activities. Inspectors and relatives said the home still needed to develop more meaningful activities and social opportunities.
“The restrictions imposed by the pandemic had impacted on the progress of supporting people to develop a programme of meaningful activities.” from the report
Complaints records
minorThe manager had dealt with some concerns but had not always recorded them as formal complaints. The home agreed to improve its records.
“The management culture was more open and responsive to concerns, but this was not always reflected in the records maintained.” from the report
- 01What recognised Positive Behaviour Support and autism training has now been completed by staff?
- 02How are people's weight, diet and use of snacks being monitored and reviewed?
- 03What regular activities and community opportunities are now available for each person?
- 04How are complaints and informal concerns recorded, investigated and followed up?
- 05What independent checks now make sure the improvements are being maintained?
This inspection reviewed all five key questions, the care provided and the premises, and also included infection prevention and control measures. This explanation was written from the published report of 8 July 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.
What inspectors found, January 2021
Overall rating remains Inadequate; inspectors found safer staffing and improving care, but this targeted visit did not re-rate the home.
Inspectors made an unannounced targeted visit on 23 November 2020. They checked staffing, safeguarding and the culture of the home. They also reviewed infection control measures.
They found enough staff to support people safely. People appeared relaxed and engaged in activities. Staff understood how to recognise and report abuse, and infection control arrangements were judged satisfactory.
Care was becoming more personalised, and the management team was working to improve the home's culture. However, the home was still larger than current best practice guidance and its culture was still changing.
This inspection did not give new ratings. The overall rating therefore remained Inadequate from the last comprehensive inspection. The Safe and Well-led questions were inspected but not rated, because only specific concerns were checked.
Staffing
Inspectors found enough staff to meet people's needs safely. Rotas showed that minimum staffing levels had been maintained, including when staff had to self-isolate.
“Staffing levels were sufficient to look after people safely. The atmosphere was calm and relaxed, and people were engaged in individual activities” from the report
Safeguarding
Staff understood what abuse could involve and knew what action to take. Incident records were completed and possible triggers for people's behaviour were explored.
“Staff demonstrated that they understood what constituted abuse and knew the action they should take if they witnessed it.” from the report
Person-centred support
People were supported to follow their own routines and move freely around the home. Care was becoming more focused on individual needs, dignity and rights.
“People continued to receive a more person-centred approach to their support. People were observed moving freely around the service and followed their own individual routines.” from the report
Infection control
Inspectors were assured that the home was using protective equipment safely, supporting testing and following infection control measures.
“We were assured that the provider was using PPE effectively and safely.” from the report
Overall rating remains Inadequate
seriousThe previous comprehensive inspection rated the home Inadequate. This targeted inspection did not change that rating because it did not assess the whole service.
“The overall rating for the service has not changed following this targeted inspection and remains Inadequate.” from the report
Limited inspection
needs fixingThe visit only checked specific concerns about staffing, safeguarding and culture. It did not provide a full review of all five areas of care.
“Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.” from the report
Culture and size of the home
needs fixingThe management team was still working to change an institutional culture. The home was also larger than current best practice guidance, although steps had begun to make it feel more domestic.
“The management team were still working hard to change the previously institutionalised culture within the service.” from the report
- 01What actions from the improvement plan are still outstanding, and how will you show that improvements have been maintained?
- 02How do you make sure five care staff are available on every shift, including when someone is sick or self-isolating?
- 03What has changed to reduce the previously institutionalised culture and make support more person-centred?
- 04How are people's rooms and shared areas being personalised to make the home feel more domestic?
- 05How are safeguarding incidents and possible behaviour triggers reviewed, and how are lessons shared with staff?
This was an unannounced targeted inspection of specific concerns about staffing, safeguarding and culture, with an infection control review; it did not reassess the full service or change the previous ratings. This explanation was written from the published report of 21 January 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
7 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- July 2021Requires improvementcurrent ratingSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2021Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- October 2020Inadequatestayed InadequateSafe: Requires improvementWell-led: Requires improvement
- May 2020Inadequatestayed InadequateSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- April 2020Inadequatestayed InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- May 2019Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- February 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2014
Report published without a new overall rating.
- September 2013
Registered with the Care Quality Commission on 26 September 2013.
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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