CQC report explained · a nursing home
What the CQC found at Ashley Gardens Care Centre
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, January 2023
Ashley Gardens Care Centre was rated Requires Improvement overall and placed in special measures; Safe was rated Inadequate because risks, medicines and staffing were not managed reliably.
Inspectors made unannounced visits on 10 and 14 November 2022. They spoke with people, relatives, staff and visiting professionals. They reviewed care plans, risk assessments, medicines records, audits and recruitment files.
They found serious safety problems. Some people did not receive the care needed for constipation, diabetes or low fluid intake. Some medicines were late or not given as planned. There were times when too few staff were available, including during meals and when people needed help to use the toilet.
There had been improvements since the previous inspection. Falls management, complex eating and drinking support, fire safety, skin care and care planning had improved. Safeguarding arrangements had also improved, so the home was no longer in breach of that regulation.
The overall rating changed from Inadequate to Requires Improvement, but Safe remained Inadequate and Well-led was Requires Improvement. The home was placed in special measures because an inadequate key-question rating had continued across two comprehensive inspections.
Safeguarding improved
Staff and managers knew how to report safeguarding concerns. The home tracked alerts and had sent possible concerns about medicines to the local safeguarding team.
“Enough improvement had been made at this inspection and the provider was no longer in breach of regulation 13.” from the report
Better falls support
The report says there had been a large reduction in falls. Falls were recorded, monitored and reviewed, with referrals to falls clinics where needed.
“Since the last inspection there had been a large reduction in falls and falls management had significantly improved.” from the report
Eating and drinking support
People with complex eating needs were supported with the correct position and food consistency. Food and weight records were being monitored.
“We found a significant improvement in the support people received with complex eating conditions” from the report
Kind interactions
Inspectors observed caring interactions. One person said staff were kind and caring.
“The staff are kind and caring; you can't fault anything to do with that.” from the report
Unsafe care and medicines
seriousSome health risks were not monitored or treated as planned. Examples included missed constipation treatment, unsafe diabetes monitoring, late medicines and incomplete incident records.
“The provider had failed to assess, monitor and manage risks to service users' health and safety, provide safe care and treatment, manage medicines safely, or ensure lessons were learnt.” from the report
Not enough staff at times
seriousInspectors saw people left waiting for help and people at risk of falls without staff or a call bell nearby. The staffing tool did not reflect people's current needs.
“The failure deploy sufficient numbers of suitably qualified, competent, skilled and experienced staff is a continued breach of Regulation 18” from the report
Weak audits and oversight
seriousAudits did not always identify bruising, missed bathing or other care concerns. High staff turnover and agency nursing shifts also affected how information was shared.
“The failure to ensure quality assurance and governance systems were effective and risks to people's safety were identified and managed safely is a continued breach of Regulation 17” from the report
Limited community access
minorThe report says there were limited opportunities for people to access the local community. The new management team knew this needed work.
“There were limited opportunities for people to access their local community” from the report
- 01What has changed since the inspection to make sure diabetes checks, constipation care and fluid monitoring are completed at the right times?
- 02How do you now make sure medicines, including as-required pain relief, are given on time and their effect is recorded?
- 03What are the current staffing levels during mornings, mealtimes and nights, and how are they matched to residents' needs?
- 04How are accidents, bruising and other incidents now reported, reviewed and used to prevent a repeat?
- 05Has a registered manager now been appointed, and what do the latest monthly audits show about these risks?
This unannounced comprehensive inspection focused on the Safe and Well-led key questions, including infection prevention and control; the report does not give ratings for the other three questions. This explanation was written from the published report of 25 January 2023 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, October 2022
Ashley Gardens Care Centre rated Inadequate and placed in special measures; inspectors found serious risks to people's safety and weak management.
This was an unannounced focused inspection. Inspectors visited on 30 June and 1 July 2022, then continued checking records and speaking with staff, relatives and health and social care professionals. They looked only at Safe and Well-led.
The home was rated Inadequate for Safe and Well-led. Inspectors found that risks involving falls, choking, medicines, diabetes, personal care, fire safety and behaviour were not always assessed or managed safely. They also found unsafe restraint, safeguarding concerns, staff skill and staffing problems, and inaccurate care records.
The home had not made enough improvement since its previous Requires Improvement rating, published on 29 March 2022. Some infection control arrangements were satisfactory, and two relatives said they were happy with the support their family members received.
The overall rating is Inadequate and the home is in special measures. This means CQC will keep it under review and normally re-inspect within six months to check for significant improvement.
Infection control
Inspectors were assured that infection prevention arrangements were in place, including measures for visitors, protective equipment, testing and outbreaks.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Some family satisfaction
Two relatives said they were happy with the support their family members received. One relative also said communication with the manager was open.
“Two relatives we spoke with told us they were happy with the support their family member received at the service.” from the report
Choking and eating risks
seriousStaff did not always follow agreed steps to reduce choking risks. Inspectors also found that food and drink monitoring was incomplete and suction machines were not always ready for use.
“During our visits we observed staff not following agreed actions to prevent people choking when eating.” from the report
Falls and moving equipment
seriousThere had been many falls, including serious injuries. Staff did not always follow mobility plans or know how to use moving and handling equipment safely.
“Since the last inspection there had continued to be a high number of people falling, resulting in serious injuries including bone fractures and head injuries.” from the report
Medicines and diabetes
seriousMedicines were not always given as prescribed or recorded safely. One person went three consecutive days without insulin and was at serious risk of harm.
“There had been three consecutive days where the person had not received their insulin medicine to help control their diabetes which placed them at serious risk of harm to their health.” from the report
Abuse and restraint safeguards
seriousSystems for protecting people from abuse and improper treatment were not effective. Inspectors found continued risks of unauthorised restraint and several allegations involving abuse or neglect.
“During this inspection we found people were at continued risk of unauthorised restraint.” from the report
Staff skills and staffing
seriousRotas did not always provide enough suitably skilled staff. Agency staff were used heavily, and staff did not always know how to meet people's needs safely.
“Although further training was planned to be delivered to address staff knowledge gaps, we observed, and staff told us they did not always know how to meet people's needs safely.” from the report
Weak management checks
seriousThe home's audits and action plans had not resolved earlier problems. Care records remained inaccurate or out of date, and staff were not always clear about their responsibilities.
“Multiple breaches of regulations had re-occurred since the last inspection, placing people at actual and avoidable risk of harm to their health and well-being.” from the report
- 01What specific changes have been made to prevent choking, and how do you check that staff follow each person's eating and drinking plan?
- 02How are falls reviewed now, and how do you make sure staff use the correct mobility and moving equipment?
- 03How do you check that medicines, including insulin and as-needed pain relief, are given exactly as prescribed?
- 04What has changed about staffing, agency staff supervision and staff training since this inspection?
- 05How are you checking that care records are accurate, up to date and followed by all staff?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried over from the previous inspection. This explanation was written from the published report of 14 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.
Every inspection of Ashley Gardens Care Centre
4 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- January 2023Requires improvementcurrent ratingup from InadequateSafe: InadequateEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2022Inadequatedown from Requires improvementSafe: InadequateWell-led: Inadequate
- May 2022Requires improvementdown from GoodSafe: InadequateWell-led: Requires improvement
- September 2017GoodSafe: GoodResponsive: OutstandingWell-led: Good
- February 2016
Registered with the Care Quality Commission on 26 February 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.
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