CQC report explained · a nursing home
What the CQC found at Ashmead Care Centre
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, safe recruitment, regular risk reviews and safe medicines administration. Infection prevention arrangements, including PPE and COVID-19 procedures, were also found to be effective.
- Effective?
- Good
- This key question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Responsive?
- Requires improvement
- People did not always have enough opportunities to take part in activities of their choice. Inspectors also said care plans, mealtimes and some communal areas could better support individual wellbeing.
- Well-led?
- Good
- Inspectors found open leadership, clear responsibilities and thorough, up-to-date audits. People, relatives and staff said managers listened and acted on feedback.
What inspectors found, September 2022
Rated Good overall, but inspectors found the home was not always responsive to people's activities and wellbeing needs.
This was an unannounced inspection on 9 and 11 August 2022. Inspectors spoke with 23 people, six relatives, 13 staff and three healthcare professionals. They also checked care records, medicines records, staffing information, risk assessments and management audits.
The home was rated Good for Safe and Well-led. Inspectors found enough staff, safe medicines management, suitable infection control and regular checks on risks. People and relatives generally said the home was safe, and staff were described as kind and respectful.
The home was rated Requires Improvement for Responsive, as people did not always have enough suitable activities or social interaction. Inspectors also identified areas where care plans, communal spaces and mealtimes could better reflect people's individual needs. The overall rating remained Good, and the previous rating was also Good.
Safe staffing
Inspectors found enough staff to meet people's needs and saw that staffing levels matched the rota. Recruitment checks were also completed before staff started work.
“There were enough staff to meet people's needs.” from the report
Medicines and infection control
Medicines were administered and recorded safely. The home also had up-to-date infection control arrangements and staff used PPE appropriately.
“Medicines were safely administered, regularly audited and appropriately stored and disposed of.” from the report
Kind, personalised care
People were supported to make choices and follow their routines and preferences. Inspectors observed positive interactions between staff and people.
“People were provided with person-centred care by staff who knew them and their preferences well.” from the report
Open management
The management team was described as open and honest. Audits and quality checks were thorough, and complaints and incidents were reviewed.
“The home had a management and leadership team that was transparent with a culture of openness, positivity and honesty.” from the report
Not enough suitable activities
needs fixingPeople did not always have enough meaningful activities or opportunities to socialise. The home had started staff training and had recruited an activities co-ordinator, but the programme was still developing.
“People were not always provided with enough opportunities to engage with others and take part in activities of their choosing.” from the report
Care plans did not always reflect the person
needs fixingSome care records were more focused on tasks than on the person's life and interests. Inspectors also found that staff did not always use one person's chosen name and gender consistently.
“It was however difficult to see how this knowledge was applied to the care plans in place and, overall, the care plans appeared task not person focussed.” from the report
Mealtimes and shared spaces
needs fixingInspectors said some mealtimes were not well coordinated and that parts of the home were sparse or not welcoming. They recommended reviewing these areas to improve people's experience.
“We recommend the provider reviews how some areas of the home and mealtimes can be better used to enhance the experience of people using the service.” from the report
- 01What activities are now available for people who prefer individual activities, and how are these matched to each person's interests and abilities?
- 02Has the activities co-ordinator started, and what changes have been made since the inspection?
- 03How do staff use people's life histories and interests in daily care and conversation?
- 04How do you make sure every person's chosen name and gender are used consistently in care records and daily notes?
- 05What changes have been made to mealtimes and communal areas, including the dining room and balcony?
This was an unannounced focused inspection that looked at Safe, Responsive and Well-led; Effective and Caring were not inspected and their previous ratings were used for the overall rating. This explanation was written from the published report of 21 September 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 2022
Inspected but not rated; inspectors found robust COVID-19 infection controls during an outbreak.
This was a targeted inspection on 18 January 2022. Inspectors checked infection prevention and control, visiting arrangements and whether COVID-19 staff pressures affected care. The visit was announced one day beforehand.
Inspectors found strong measures to reduce infection risks. Staff used personal protective equipment correctly, supplies were adequate, testing was regular and the home was clean. The home had plans for outbreaks, staff shortages and people at higher risk.
People could still receive visits in line with government guidance, and staff helped people keep in touch by telephone and video calls. The home was not taking new admissions while there was a COVID-19 outbreak.
The service was inspected but not rated overall. Safe was also marked inspected but not rated. This report does not give ratings for the other four questions and does not provide a new overall quality rating.
Infection control
Inspectors found the infection prevention measures robust. Staff used PPE properly and had updated training.
“The measures in place were robust and effective in preventing and minimising the risk to people, staff and those that visited the care home from catching or spreading COVID-19.” from the report
Testing and outbreak planning
The home tested people twice a week and had plans for outbreaks and staff shortages.
“They included specific Covid-19 related risk assessments for people, and contingency plans for managing adverse events, including COVID-19 outbreaks and staff shortages.” from the report
Clean environment
The home was clean and kept detailed cleaning records, including regular cleaning of surfaces that people often touch.
“The care home was clean, hygienic and detailed records were kept of cleaning schedules.” from the report
Keeping people connected
Although visiting was restricted during the outbreak, staff supported people to maintain contact through calls and video calls.
“Staff actively supported people to keep in touch with those who could not visit the care home in-person, via telephone and video calls.” from the report
Staff arrangements
The provider did not use agency staff. Bank staff worked only in this home and on designated floors to reduce infection risks.
“The provider did not use agency staff and ensured bank staff worked exclusively in the one care home and on specific designated floors to reduce the risk of spreading infection.” from the report
COVID-19 outbreak
minorThere was an outbreak at the time of the inspection. New admissions were paused, and visiting was restricted, although designated visitors could still attend under the guidance.
“The home was not currently taking new admissions due to a Covid-19 outbreak.” from the report
- 01Has the COVID-19 outbreak ended, and are you now accepting new admissions?
- 02How are visits currently arranged, including visits during any future outbreak?
- 03How often are residents and staff tested for COVID-19 now?
- 04What staffing pressures are currently affecting the home, and how would these affect my relative's care?
- 05How do you manage people returning from hospital, including testing and isolation?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; it did not rate the other four key questions or give an overall rating. This explanation was written from the published report of 3 February 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 Ashmead Care Centre
3 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- September 2022Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- February 2022Inspected but not ratedSafe: Inspected but not rated
- September 2019Goodup from Requires improvementSafe: GoodResponsive: Requires improvementWell-led: Good
- September 2018Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2017
Registered with the Care Quality Commission on 30 July 2017.
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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