CQC report explained · a residential care home
What the CQC found at Ashleigh Manor Residential Care Home
Not yet rated: the CQC has not published a rated inspection for this home, which is usual for a new registration.
What inspectors found, October 2022
Rated Good; inspectors found improved, personalised care, with monitoring of important activities still needing attention.
This was an unannounced focused inspection. Inspectors visited on 29 September 2022 and completed inspection activity until 4 October 2022. They spoke with people, staff, relatives and a social care professional, and reviewed care plans, audits and other records.
The home was rated Good overall. Effective, Responsive and Well-led were rated Good. Inspectors found better staff training, improved activities, personalised care plans, good support with food and health, and stronger checks on the quality of care.
This inspection did not assess Safe or Caring. Their ratings were carried forward from the previous inspection. The previous overall rating was Requires Improvement, with breaches of regulations. The report says the home had improved and was no longer in breach.
Inspectors recommended better monitoring of whether people regularly received activities and pastimes that mattered to their mental health and wellbeing.
Improved staff training
The home had a training plan and competency assessments to check that staff understood their training and could meet people's needs.
“There was a training plan in place to help ensure all staff had completed required training.” from the report
Personalised dementia support
Staff knew people's preferences and used them to tailor care. The home also made changes to bedrooms and communication tools to support people living with dementia.
“Staff knew the people they cared for and tailored support to meet their needs.” from the report
More activities
People had group and one-to-one activities, could suggest ideas and were supported to use the garden. The increased activity had a positive effect on people's lives and staff morale.
“People benefitted from a programme of group activities but also had one to one time with staff if this was their preference.” from the report
Stronger management checks
There were clearer responsibilities, regular audits and meetings. Inspectors found that action was taken when improvements were identified.
“Senior staff, the registered manager and provider all completed audits and checks of the service.” from the report
Important activities were not monitored
minorThe home provided activities and interests that mattered to people, but did not check records to make sure each person received them as often as needed. CQC made a recommendation about this.
“Where people had key activities or interests that were important to their mental health.these were available but no-one monitored records to help ensure people were able to do these things as often as they needed.” from the report
- 01How do you record and review the activities, interests and pastimes that are important to my relative?
- 02How often will you check that my relative is taking part in those important activities?
- 03How will you keep my relative's care plan updated as their needs and preferences change?
- 04What training and competency checks have staff completed for supporting people living with dementia?
- 05How will you tell me about changes in my relative's health or wellbeing?
This was a focused inspection of Effective, Responsive and Well-led; Safe and Caring were not inspected and their ratings were carried forward from the previous inspection. This explanation was written from the published report of 26 October 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 2022
Rated Requires Improvement; inspectors found safe medicines and kind care, but concerns remained about training, activities, staffing and management.
This was an unannounced focused inspection carried out on 11, 14 and 17 March 2022. Inspectors spoke with people, staff and relatives, reviewed care and medicines records, observed care, and checked how the home was managed.
The home was rated Good for Safe. People were protected from avoidable harm, medicines were managed safely, recruitment checks were completed, and infection control arrangements were suitable. However, some people and relatives felt staff were rushed and that the home was short staffed.
Effective, Responsive and Well-led were rated Requires Improvement. Staff training was not always up to date, people did not have enough meaningful activities, and checks by the provider had not identified or fixed all the problems. The home remained in breach of regulations, as it had at the previous inspection.
Safe medicines
People received their medicines safely and as prescribed. The home had suitable arrangements for storage, ordering and disposal, with regular medicines audits.
“People received their medicines safely as prescribed for them.” from the report
Personalised care
Care plans described people's needs, choices and preferences. Staff knew people well and supported them to make choices during the day.
“People had clear care plans in place which documented their choices and preferences as well as their needs.” from the report
Health support
The home monitored people's health and contacted outside health professionals when needed. Staff and relatives said health needs were dealt with promptly.
“Staff and relatives reported people's health care needs were dealt with promptly.” from the report
Raising concerns
People and relatives felt able to raise concerns. Inspectors saw concerns being dealt with and found clearer information about how to complain.
“Relatives told us they knew who to talk about if they had a concern and felt confident doing this.” from the report
Staff training
seriousNot all staff had completed or updated important training, including training on falls, skin care, diabetes, safeguarding and catheter care. This was a breach of Regulation 18.
“Staff had not all completed or updated training the provider had allocated as mandatory.” from the report
Too few meaningful activities
seriousPeople did not have enough activities that matched their interests and preferences. This was a breach of Regulation 9 and led to a warning notice.
“People didn't always have enough to do.” from the report
Staffing and deployment
seriousSome people, relatives and staff said staff were rushed and that the home felt short staffed. The provider was told to improve staffing levels and how staff were deployed.
“Staff confirmed they were rushed at times.” from the report
Management checks
seriousThe provider completed audits but these did not identify all the problems found by inspectors. Not enough action had been taken on known concerns, which was an ongoing breach of Regulation 17.
“They had failed to identify the required improvements we found during the inspection.” from the report
Fluid records
needs fixingRecords showed how much people drank, but did not say how much each person needed. This made it harder to identify when someone had not drunk enough.
“This made it difficult to identify if someone hadn't had enough to drink.” from the report
- 01What training has every member of staff now completed in safeguarding, falls, skin care, diabetes and catheter care?
- 02How do you decide how many staff are needed on each shift, and how do you respond when staff feel rushed?
- 03What regular activities are now available for people with dementia, including activities based on their individual interests?
- 04How do you record the amount each person needs to drink, and how do you act if they are not drinking enough?
- 05What action has been taken following the warning notices about activities and management checks?
This was a focused inspection of Safe, Effective, Responsive and Well-led; Caring was not inspected, and any key question not inspected used its previous rating when calculating the overall rating. This explanation was written from the published report of 12 May 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.
Every inspection of Ashleigh Manor Residential Care Home
10 rated inspections over 7 years: the service has held its Good rating throughout.
- October 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Ashleigh Manor Residential Care Home →
- May 2022Requires improvementstayed Requires improvementEffective: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
Read what inspectors found at Ashleigh Manor Residential Care Home →
- August 2021Requires improvementdown from GoodSafe: GoodEffective: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2020Goodup from Requires improvementSafe: GoodWell-led: Good
- November 2019Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2019Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- August 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- October 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2016Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 23 November 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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