CQC report explained · a residential care home
What the CQC found at Ashley Court Care 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
- People were protected from abuse and there were enough staff, but recruitment records were incomplete. Medicines storage and external-medicine records were not always clear, and the fire alarm had faults during the visit.
- Effective?
- Good
- This question was not inspected during this focused visit.
- Caring?
- Good
- This question was not inspected during this focused visit, although people and relatives spoke positively about the care and staff.
- Responsive?
- Good
- This question was not inspected during this focused visit.
- Well-led?
- Requires improvement
- The management team was open and acted quickly when issues were identified. However, its audits had not found the recruitment and medicines shortfalls, and there had been delays dealing with the fire alarm.
What inspectors found, October 2022
Rated Requires Improvement; inspectors found caring support but weaknesses in recruitment, medicines systems and fire alarm repairs.
This was an unannounced focused inspection on 28 July 2022. Inspectors looked only at whether the home was safe and well-led. They spoke with people, relatives and staff, observed care, and reviewed medicines, care records, recruitment files and management checks.
People and relatives said they felt safe and spoke positively about the staff. There were enough staff to meet people's needs, risks were assessed, infection control arrangements were satisfactory, and the home supported people's choices and worked with health professionals.
However, two recruitment files were missing important information. Medicine storage and records for creams were not always clear. The fire alarm system had faults and sometimes sounded for long periods, although the provider confirmed that upgrade work was completed on 29 August 2022.
The overall rating changed from Good to Requires Improvement. Safe and Well-led were both rated Requires Improvement. The home breached Regulation 19 because recruitment checks were not robust. CQC requested an action plan and will monitor progress.
Enough staff
People and relatives said there were enough staff. Inspectors saw staff respond promptly when people asked for help.
“There were enough staff available to meet people's needs.” from the report
Risk management
The home assessed risks such as falls and skin damage. Equipment was used to help reduce these risks.
“Potential risks to people's care and safety were assessed and kept under review to promote their safety.” from the report
Open management
Managers were open during the inspection and took immediate action on several issues found.
“We found the registered manager and the nominated individual were open and transparent throughout the inspection and took immediate action to address the shortfalls found during the inspection.” from the report
Infection control
Inspectors were assured about the home's arrangements for preventing and managing infections, including its use of protective equipment.
“We were assured that the provider was using PPE effectively and safely.” from the report
Recruitment checks
seriousBoth recruitment files inspected were missing information about education and work history, including gaps that had not been explored. This led to a breach of Regulation 19.
“The provider had failed to operate robust recruitment and selection practices.” from the report
Medicine records
needs fixingA staff drink was stored in the medicines fridge, and records for applying creams were unclear. The manager acted immediately to address these problems.
“Good practice was not always followed when storing medicines.” from the report
Quality checks
needs fixingThe home's audits had not identified the recruitment and medicines problems before the inspection. This contributed to the Well-led rating of Requires Improvement.
“However, the areas identified during the inspection, around staff recruitment and medicines management had not yet been identified in the audits.” from the report
- 01What evidence can you provide that all staff files now contain complete education and work histories, references and other required checks?
- 02How do you now check that medicines, including creams, are stored and recorded correctly?
- 03When was the fire alarm upgrade completed, and has it since been tested and signed off?
- 04How will your audits identify recruitment and medicines problems before they affect people's safety?
- 05What progress has been made on the action plan requested by CQC?
This was a focused inspection of Safe and Well-led only; the other three ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 1 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, February 2021
Ashley Court Care Home was rated Good overall, but Safe Requires Improvement because risk checks, recruitment records and cleaning records were not always complete.
Inspectors visited on 18 December 2020 because of concerns about safety and how the home was managed. They spoke with people, relatives and staff, and reviewed care records, medicines records, staff files and management documents.
The home was rated Good overall. Inspectors found that people felt safe, medicines were managed safely, there were enough staff and staff were trained and supported. Care was person-centred, and people and relatives spoke positively about the staff and management.
Safe was rated Requires Improvement. Some falls risks had not been reviewed, window restrictors did not meet safety requirements, recruitment records were incomplete and cleaning records did not consistently show that high-touch areas had been cleaned. Well-led was rated Good, although the home was asked to review its checks and audits.
Safe medicines practice
Inspectors found that medicines were administered safely and that staff received training, support and checks.
“Medicine records evidenced that people received their medicines as prescribed and there was clear guidance in place to support staff to administer safely.” from the report
People felt safe
People and relatives said they felt safe, and staff understood how to recognise and report abuse.
“People were protected from the risk of abuse. Staff had received training in safeguarding and had a good understanding of recognising the signs of abuse and how to report it.” from the report
Person-centred care
Staff knew people well and considered their individual needs and communication needs.
“There was a regular team of staff that knew people well and who had a good understanding of people's individualised needs and ensuring they felt included.” from the report
Open management
The management team was described as open and transparent and worked with other health professionals to support people.
“The management team were open and transparent throughout the inspection and keen to improve the service for the people they cared for.” from the report
Falls risks were not always reviewed
seriousOne person with more falls remained recorded as being at low risk. Another person who had recently fallen had no risk assessment or care plan.
“We found some inconsistency in risk assessing people. For example, we identified one person who had experienced increased falls but had not had a review of their risk assessment and had remained recorded as at low risk.” from the report
Window safety
seriousThe window restrictors limited openings but were not tamper-proof as required. The provider said new restrictors had been ordered after the inspection.
“However, the restrictor mechanism did not meet the health and safety executive requirements as tamper proof.” from the report
Recruitment records
needs fixingTwo new staff files were missing information such as references, a recent photograph and previous work history. All staff did have DBS checks.
“We identified missing information in two new staff members files such as references, recent photo and previous work history.” from the report
Cleaning records
needs fixingThe home appeared clean, but records did not consistently show that high-touch areas had been cleaned frequently.
“Cleaning records were not consistently completed to evidence frequent cleaning of high touch areas to prevent the spread of infection.” from the report
Quality checks missed problems
needs fixingThe home's audits had not identified all the safety and record-keeping issues found by inspectors. The provider was recommended to review its systems and processes.
“We recommend that systems and processes are reviewed to ensure audits cover all aspects of the safety and quality of the service.” from the report
- 01Have all residents' falls risk assessments and care plans been reviewed and updated?
- 02Have the new window restrictors been fitted, and do they now meet the required safety standard?
- 03What checks now make sure recruitment files contain references, photographs and previous work history?
- 04How do you record frequent cleaning of high-touch areas, and who checks those records?
- 05What changes have been made to the audits so that safety and record-keeping gaps are identified promptly?
This inspection focused on Safe and Well-led; the report gives no new ratings for Effective, Caring or Responsive. This explanation was written from the published report of 13 February 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 Ashley Court Care Home
5 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- October 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2021Goodstayed GoodSafe: Requires improvementWell-led: Good
- October 2019Goodstayed GoodSafe: Requires improvementWell-led: Good
- March 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- August 2012
Registered with the Care Quality Commission on 21 August 2012.
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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