CQC report explained · a residential care home
What the CQC found at Ashley House - Langport
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, April 2023
Ashley House - Langport was rated Requires Improvement; inspectors found kind care and progress, but training, care records and management checks were still not reliable.
This was an unannounced focused inspection on 22 and 23 February 2023. Inspectors observed care, spoke with people, staff, relatives and a visiting professional, and checked care, medicines, training and management records.
The home had enough staff and people said they felt safe. Staff were caring and medicines were stored and given safely. Systems for consent, healthcare, safeguarding and the environment had improved.
However, some risk assessments and care plans lacked enough detail. Staff training was incomplete, including training for moving people, first aid and medicines. Checks on accidents, call bells and improvements did not always identify or deal with problems quickly.
The overall rating remained Requires Improvement. Safe, Effective and Well-led were each rated Requires Improvement. Caring and Responsive were not inspected in this visit, so their earlier ratings were carried forward.
Caring staff
Inspectors saw staff treating people with care and respect. People and relatives spoke positively about the support and the atmosphere.
“Throughout the inspection we observed staff interacting with people in a caring and considerate way.” from the report
Staffing and recruitment
There were enough staff to support people safely, and the required recruitment checks had been completed.
“There were enough staff to support people safely.” from the report
Medicines
Medicines were stored and administered safely. Staff gained consent and recorded medicines after giving them.
“Medicines were stored and administered safely.” from the report
Healthcare support
The home had improved how it worked with GPs and district nurses, and records showed people received timely healthcare support.
“We reviewed people's care records which demonstrated the service sought timely and appropriate advice and guidance from health professionals to meet people's health care needs.” from the report
Improved management culture
Staff and relatives said communication and support had improved under the new management team. The manager accepted feedback and started taking action.
“The registered manager was creating a culture that was more open and supportive.” from the report
Incomplete staff training
seriousThe home could not show that all required training had been completed. Two staff members who were giving medicines did not have up-to-date competency assessments.
“The provider had failed to ensure staff received sufficient training to enable them to carry out their roles.” from the report
Care records and risk plans
needs fixingSome care plans and risk assessments did not give staff enough detail to provide safe, consistent support for individual needs.
“The care plans and risk assessments in use were not always robust and did not provide sufficient information.” from the report
Weak management checks
seriousThe new monitoring systems were not yet working reliably. Some incident actions were overdue, call-bell monitoring had no records, and improvement plans lacked clear deadlines.
“Systems and processes were not operated effectively to assess, monitor and improve the quality and safety of the service.” from the report
Activities
minorRelatives wanted more activities, and the home was recruiting an activities coordinator.
“Relatives spoken with mentioned the lack of an activities coordinator and more activities as being an area where they would like to see improvement.” from the report
- 01Have all staff now completed the required training, including moving people, emergency first aid, mental capacity and medicines competency checks?
- 02Have each person's care plans and risk assessments been reviewed and updated with enough detail for their individual needs?
- 03What has been done about the incident action that was still outstanding, and how are accidents and incidents now reviewed for learning?
- 04Are call-bell response times now recorded and checked, and what have those checks shown?
- 05Has an activities coordinator been appointed, and what activities are now available?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 7 April 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
Rated Requires Improvement; inspectors found kind care and safe medicines, but serious gaps in risk management, staff training and management oversight.
Inspectors visited on 11 and 12 August 2022. They spoke with people, visitors and staff, observed care, and checked care records, medicines, recruitment files, safety checks and management records. The inspection followed an incident after which a person died, but the report says the circumstances of that incident were not examined because of a police investigation.
Inspectors found risks were not always identified or managed. These included broken windows, unlocked cupboards, fire escape problems, falls and gaps in staff training. They also found inconsistent checks on people's legal rights when restrictions were used, including delays in renewing some safeguards.
People received medicines safely, infection control was satisfactory, and inspectors saw kind and caring interactions. However, the overall rating was Requires Improvement. Safe, Effective and Well-led were all rated Requires Improvement. Caring and Responsive were not rated in this inspection.
Medicines
Inspectors found medicines were stored, administered and recorded safely. Staff had medicines training and competency checks.
“Medicines were safely managed. Processes were in place for the ordering and supply of medicines and medicines administration records (MAR) indicated people received their medicines at the right time.” from the report
Kind interactions
Inspectors saw caring and compassionate contact between staff and people. People appeared comfortable and relaxed, and people and relatives gave positive comments about the care.
“We observed kind, compassionate and caring interactions between people and staff.” from the report
Infection control
The inspection found suitable measures for preventing and managing infections, including the use of protective equipment.
“We were assured that the provider was using PPE effectively and safely.” from the report
Recruitment checks
The home completed the required checks before employing staff, including criminal record checks and references.
“All required pre-employment checks had been carried out including criminal record checks and obtaining references from previous employers.” from the report
Risks and fire safety
seriousInspectors found that risks to people's health and safety were not consistently assessed, monitored or managed. Problems included broken windows, unlocked cupboards, falls and fire escape arrangements.
“The provider had failed to assess, monitor and manage risks to service users' health and safety and provide safe care and treatment.” from the report
Staff training and supervision
seriousSome staff were working without required training, including fire safety, first aid, moving and handling, falls awareness, safeguarding, dementia care and legal safeguards. Supervision was also not regular enough.
“Staff did not receive effective and sufficient supervision and training to enable them to carry out their roles.” from the report
Consent and legal safeguards
seriousThe home did not consistently assess people's ability to consent or record best-interest decisions. Its system for monitoring legal safeguards and expiry dates was not effective.
“Systems to ensure people received care in line with the MCA and DoLs were inconsistent.” from the report
Management oversight
seriousAudits and other checks did not reliably identify problems or ensure they were corrected. There was also limited learning from accidents and incidents and insufficient action on feedback.
“Systems and processes were not operated effectively to assess, monitor and improve the quality and safety of the service.” from the report
- 01What has been done to make broken windows, unlocked hazardous cupboards and the external fire escape safe?
- 02How do you now investigate falls and other incidents, identify patterns and prevent them happening again?
- 03Which staff still need training or refresher training, and how do you check they are competent before supporting people?
- 04How do you monitor consent decisions and make sure any Deprivation of Liberty Safeguards applications are renewed before they expire?
- 05What changes have been made to management audits, staff supervision and feedback from residents, relatives and staff?
This inspection focused on Safe, Effective and Well-led following safety concerns; Caring and Responsive were not rated, and the previous overall rating was Good. This explanation was written from the published report of 5 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 House - Langport
5 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- April 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2022Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- April 2021Inspected but not ratedSafe: Inspected but not rated
- April 2020Goodstayed GoodSafe: Requires improvementWell-led: Good
- May 2018Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
- February 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 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.
- January 2011
Registered with the Care Quality Commission on 19 January 2011.
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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Most charge £1,020 to £1,370 a week. 62 can care for a couple. 12 years' experience on average.
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