CQC report explained · a nursing home
What the CQC found at Ashlynn Grange
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found weaknesses in safeguarding, risk assessments, pressure-relieving equipment checks, medical device checks and medicines management. People told inspectors they felt safe, and staffing, recruitment and infection control were satisfactory.
- Effective?
- Good
- People's needs were assessed before admission, staff received relevant training, and people were supported with food, healthcare and legal decision-making. Some relatives felt healthcare reviews were not always recognised or arranged promptly.
- Caring?
- Good
- People gave positive feedback about staff being kind, respectful and caring. Inspectors also saw some inconsistent practice around privacy, dignity and reassurance.
- Responsive?
- Requires improvement
- Activities were limited and people were not always involved in care planning. End of life planning was a strength, but relatives gave mixed feedback about communication and how complaints were handled.
- Well-led?
- Requires improvement
- The new manager and senior team had made improvements and were responsive to feedback. However, audits and governance systems had not identified or acted on several important safety and quality problems.
What inspectors found, August 2023
Rated Requires Improvement; inspectors found kind care and recent improvements, but safety, activities and management systems were not consistently reliable.
This was an unannounced inspection prompted by concerns about safe care and treatment, safeguarding, person-centred care and good governance. Inspectors spoke with people, relatives, staff and healthcare professionals, and reviewed care, medicine, staffing and quality records.
People generally said they felt safe and received kind care. Staffing levels, recruitment, infection control, staff training, food and support with legal decision-making were viewed positively. End of life care planning was also detailed and personalised.
However, the home did not always manage medicines, medical devices, pressure-relieving equipment or safeguarding concerns safely. Activities and involvement in care planning were inconsistent. Complaints information and communication also needed improvement.
The overall rating fell from Good at the previous inspection to Requires Improvement. The home had made several changes with local authority support, including appointing a new manager and recruiting an activities team, but the CQC said improvements still needed to become reliable and lasting.
Kind and respectful staff
People consistently described staff as kind and caring. Inspectors observed many positive, respectful interactions.
“The staff are really nice, kind, and caring. They are nice to me, and I am happy with them.” from the report
Staffing and recruitment
The home had assessed staffing needs, recruited more staff and reduced its use of agency staff. People said their needs were responded to promptly.
“The provider had undertaken successful staff recruitment in recent months, this meant less agency staff were being used at the service.” from the report
Staff training
Staff received training linked to people's needs. New staff had a structured induction and inexperienced staff could complete the Care Certificate.
“New staff completed a comprehensive induction when starting their role and worked with experienced members of the team.” from the report
End of life planning
End of life care plans included people's wishes about where they wanted care, who should be present and their preferred environment.
“End of life care plans were personalised and contained specific information relating to the persons preference for place of care, who they would like to be present, and how they would like their environment.” from the report
Food and nutrition
Meals appeared appetising, staff knew people's dietary needs and people were shown food choices. Additional nutritional support was provided where assessed as necessary.
“People were offered a visual option of food at mealtimes, which assisted them to make informed choices.” from the report
Safeguarding and learning from incidents
seriousPotential abuse, including unexplained bruising, was not always identified or reported correctly. The home also did not always act promptly after incidents to prevent similar harm.
“The provider failed to ensure neglectful practice was identified and responded to appropriately.” from the report
Medicines and clinical equipment
seriousMedicines were not always managed safely, including missing plans for some when-required medicines. Medical devices and pressure-relieving mattresses were not always checked or used correctly.
“Medicines were not always used safely.” from the report
Risk management
seriousSome risks were not assessed or monitored properly. Inspectors found an unsecured clinical room and a fire door that had not been connected to the fire panel since December 2022.
“People were at risk of pressure sores and further skin deterioration.” from the report
Activities and social contact
needs fixingActivities were limited across the communities, and people cared for in bed did not have planned regular support and interaction. A new activities team was being recruited during the inspection.
“During our inspection visits people were not being regularly supported to follow interests and take part in activities.” from the report
Involvement and communication
needs fixingPeople and relatives were not always involved in care planning. Relatives also gave mixed feedback about communication and how to raise concerns.
“There were inconsistencies in involving people or their relatives in care planning.” from the report
Quality checks
seriousAudits and governance systems did not identify several problems found by inspectors. This meant action was not always taken quickly enough to improve safety and care.
“Governance and quality checks were not always effective in identifying areas for improvement.” from the report
- 01What action has been completed to make medicine administration and when-required medicine plans safe?
- 02How are pressure-relieving mattresses and other medical devices now checked, and how are these checks recorded?
- 03How are safeguarding concerns, unexplained injuries and medicine errors reported, investigated and used to prevent similar incidents?
- 04How many activities staff are now in place, and what regular activities are offered to people cared for in bed and people living with dementia?
- 05How will relatives be involved in care planning and kept informed when concerns or complaints are raised?
This was an unannounced inspection that looked at all five key questions and both the premises and care provided; the inspection was prompted by concerns about safety, safeguarding, person-centred care and governance. This explanation was written from the published report of 9 August 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, January 2021
Ashlynn Grange was inspected but not rated; inspectors found enough staff and good infection control during a coronavirus outbreak.
This was an unannounced, targeted inspection on 21 December 2020. Inspectors looked at infection control during a coronavirus outbreak and followed up concerns about staffing and person-centred care.
Inspectors spoke with three people, nine staff members and managers. They also checked training records, staffing rotas, meeting minutes and other management information.
They found enough staff to meet people's needs, safe recruitment and suitable infection control measures. Staff had training, PPE and access to regular testing. The home was clean and the outbreak was being managed well.
The service was inspected but not rated. This means the visit did not reassess the full service or change the previous overall rating of Good. The Safe question was also not rated at this visit.
Staffing levels
Inspectors found enough staff to meet people's needs, with care provided by a consistent staff team.
“There were enough staff available to meet people's needs. Care was provided by a consistent staff team.” from the report
Infection control
The home was clean, staff used PPE and received infection control and COVID-19 training. Inspectors said the outbreak was being managed well.
“The outbreak of infection was being well managed.” from the report
Safe recruitment
The home carried out appropriate checks before employing staff.
“Staff were recruited safely, and appropriate checks were carried out to protect people from the employment of unsuitable staff.” from the report
Safe family visits
The home had created an area where people could see relatives safely, with visitors screened and provided with PPE.
“The provider had created an area to enable people to see their relatives safely.” from the report
Cover during sickness
minorOne staff member said there had sometimes been staff shortages when people were off sick at short notice. Inspectors nevertheless found enough staff during this inspection.
“I love my job, although it has been hard as we have on occasions been short of staff due to sickness at short notice.” from the report
- 01How do you make sure there are enough staff when someone is off sick at short notice?
- 02What infection control measures are still in place following the coronavirus outbreak?
- 03How often are staff and residents tested, and what happens when a test is positive?
- 04How are visits with relatives arranged and supervised now?
- 05What action has been taken since the previous Requires Improvement rating for Safe?
This was a targeted inspection of infection prevention and control and specific staffing concerns; it did not assess the full Safe question or the other key questions, so the previous ratings were not changed. This explanation was written from the published report of 15 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 Ashlynn Grange
3 rated inspections over 6 years: the service has held its Requires improvement rating throughout.
- August 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2021Inspected but not ratedSafe: Inspected but not rated
- July 2018Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2017Requires improvementSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: Requires improvementWell-led: Good
- November 2016
Registered with the Care Quality Commission on 21 November 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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39 live-in carers within about an hour of Peterborough
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,370 a week. 34 can care for a couple. 11 years' experience on average.
“I honestly feel lucky to have found her and have already booked her for another visit.”
“Magda was always positive and proactive about trying new things to keep dad busy. She also introduced new ideas for keeping dad healthy.”
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