CQC report explained · a nursing home
What the CQC found at Ashridge Court Care Centre
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found people were protected from abuse and avoidable harm. Medicines, staffing, recruitment, equipment and infection control were managed safely, although some risk information was not personal enough.
- Effective?
- Good
- This was not inspected during this visit. The previous rating was used in calculating the overall rating.
- Caring?
- Good
- This was not inspected during this visit. The previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This was not inspected during this visit. The previous rating was used in calculating the overall rating.
- Well-led?
- Good
- Inspectors found good management oversight, an open culture and systems for monitoring quality and safety. They also found gaps in care records and noted that there was no registered manager in post.
What inspectors found, February 2021
Rated Good; inspectors found safe care and kind interactions, but some care records and bed-rest decisions needed improvement.
This was an unannounced focused inspection on 11 and 13 January 2021. Two inspectors spoke with seven people, 10 staff and health professionals. They reviewed care records, medicines records, staff files, accident records and quality checks.
The inspection looked only at Safe and Well-led. Both were rated Good. People told inspectors they felt safe and were cared for well. Staff understood safeguarding, medicines were managed safely, staffing levels met people's needs at the time, and infection control arrangements reflected current guidance.
Inspectors found that some records were too general and did not fully explain each person's needs. This included diabetic care, fluid intake and people who stayed in bed. The management team had identified these issues and began taking action. The overall rating stayed Good, with the other question ratings carried over from the previous comprehensive inspection.
Safeguarding
Staff had safeguarding training and knew how to report concerns. Referrals and notifications had been made appropriately.
“All staff had attended safeguarding training.” from the report
Medicines
Inspectors found that medicines were stored, given and disposed of safely. Records showed people received them as required.
“Medicines continued to be stored, administered and disposed of safely.” from the report
Infection control
The home was clean and well maintained. Inspectors were assured about PPE, testing, admissions and outbreak arrangements.
“We were assured that the provider's infection prevention and control policy was up to date.” from the report
Staff culture
Inspectors saw kind interactions and found staff felt supported by management. People described staff as kind, helpful and caring.
“Throughout the inspection, we saw kind and thoughtful interactions between staff and people.” from the report
Learning from incidents
Accidents and incidents were recorded and followed up. The management team looked for patterns and shared actions with staff.
“This demonstrated that learning from incidents and accidents took place.” from the report
Care records were too general
needs fixingSome care plans did not contain enough personal detail for staff to provide consistent care. Inspectors gave examples involving diabetic care and other risks.
“some peoples' diabetic care plans were generic and lacked personal specific details” from the report
People remaining in bed
needs fixingThe home had not recorded why some people remained on bed rest or assessed the possible effects. The manager agreed to review this and seek suitable solutions where equipment was a problem.
“A high percentage of people remained on continued bedrest.” from the report
Fluid records
needs fixingStaff were not recording people's fluid intake consistently. Inspectors said this could mean a change in fluid intake was missed, although people at risk of dehydration were being monitored.
“Fluid charts were discussed as there was an inconsistency in how staff recorded people's fluid intake.” from the report
No registered manager
minorThere was no manager registered with the CQC when inspectors visited. The manager had submitted an application to become registered.
“There was no registered manager in post. The previous registered manager left in September 2020.” from the report
- 01How have you updated care plans so they record each person's normal blood sugar levels and signs of high or low blood sugar?
- 02For people who remain in bed, what is the recorded reason, how are health effects reviewed, and what alternatives are being offered if they dislike the hoist?
- 03What checks now ensure staff record fluid intake consistently and identify changes quickly?
- 04Has the manager's application to register with the CQC been completed, and who is legally responsible for the home while this is pending?
- 05How do you make sure agency staff understand people's individual risks and care needs?
This was a focused inspection of Safe and Well-led only; the other ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 10 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.
What inspectors found, December 2018
Rated Good; inspectors found safe, kind and person-centred care, with some recording and call-bell improvements still being developed.
This was an unannounced comprehensive inspection on 20 and 21 November 2018. Inspectors spoke with people living in the home, relatives, staff and health professionals. They observed care and checked care plans, medicines records, staff records, incident records, audits and policies.
Inspectors found that people were safe and received care suited to their needs and preferences. Risk assessments and care plans had improved. Medicines were managed safely, there were enough staff, and staff were trained to support people with complex needs.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. This was an improvement from Requires improvement in September 2017, when inspectors had concerns about safe care and leadership.
Improved risk management
Care plans and risk assessments gave staff clearer guidance about people's health needs, including complex care such as PEG feeding and pressure-area care.
“Individual risk assessments had been implemented, reviewed and updated to provide sufficient guidance and support for staff to provide safe care.” from the report
Kind and respectful staff
Inspectors saw staff treating people as individuals, protecting their dignity and supporting their choices and independence.
“People continued to be treated with kindness, compassion and care.” from the report
Activities and personal interests
The home offered a broad programme of activities, including individual sessions for people who stayed in their rooms.
“There was a dedicated activities team that ensured 'a daily programme of interesting and therapeutic activities designed around people's tastes and needs' seven days a week.” from the report
Good communication with professionals
Health professionals said staff knew people well, responded to health concerns and acted on advice.
“They listen, take advice and act on the advice.” from the report
Care records did not fully capture emotional needs
needs fixingThe electronic care recording system was still too focused on tasks. Inspectors said further work was needed to record people's emotional needs and state of mind.
“At present it was agreed that further improvements were needed to ensure staff captured peoples' emotional needs and state of mind.” from the report
Call-bell arrangements in one unit
needs fixingCall bells in the Willow Unit were not answered as quickly as in other units because staff covered three floors. The manager had plans to rearrange the unit and consider a different call-bell system.
“The call bell audit had identified that there was a need to look at the staffing and arrangement of rooms for Willow Unit due to staff covering three floors.” from the report
Quality systems still needed embedding
minorAudits had improved, but inspectors said quality assurance systems needed to become more firmly part of everyday practice.
“Quality assurance systems needed to be further developed and embedded into everyday practice.” from the report
- 01How do you now record and review residents' emotional needs and state of mind?
- 02What changes were made to staffing or room arrangements in the Willow Unit to improve call-bell response times?
- 03What is the current average time taken to answer call bells in each unit?
- 04Have the quality assurance improvements identified in this report been fully completed and embedded?
- 05How are care plans checked to make sure they remain person-centred and up to date?
This was an unannounced comprehensive inspection covering all five key questions, and the inspection also checked whether improvements from the September 2017 inspection had been made. This explanation was written from the published report of 7 December 2018 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 Ashridge Court Care Centre
4 rated inspections over 6 years: the service has held its Good rating throughout.
- February 2021Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- November 2017Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 21 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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19 live-in carers within about an hour of East Sussex
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Most charge £1,000 to £1,400 a week. 13 can care for a couple. 10 years' experience on average.
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