CQC report explained · a residential care home
What the CQC found at Ashton Court Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, January 2021
Rated Requires Improvement; inspectors found infection-control gaps and audits that did not always identify problems, although care was kind and medicines were managed safely.
This was a planned, focused inspection because the previous rating was Requires Improvement. The inspection activity ran from 6 to 13 January 2021, including a visit on 8 January, telephone interviews and checks of care, staff and management records.
Inspectors found that infection control was not reliable. Some staff did not use personal protective equipment correctly, and visitors were not consistently screened for COVID-19 or recorded for track and trace. The home was asked to improve its monitoring of infection-control measures.
The home had enough staff, safe medicine systems, detailed risk assessments and suitable safeguarding arrangements. People appeared happy, and relatives said staff understood the people they cared for.
The overall rating stayed Requires Improvement. Safe and Well-led were both rated Requires Improvement. The home had improved enough that it was no longer in breach of Regulation 17, but its audits still did not always find or lead to improvements in care records and other areas.
Safe medicines
Medicines were stored securely and records were accurate. Staff had clear guidance for medicines given when needed.
“Medication records were up to date and accurately kept.” from the report
Enough staff
Staffing levels were based on people's needs. Inspectors saw staff respond quickly when people asked for help.
“In our observations, we saw whenever people asked for assistance, staff were quickly available.” from the report
Detailed risk planning
Care plans included detailed risk assessments and instructions for using equipment safely.
“People's care plans contained detailed risk assessments, which identified all areas where people were at risk of harm or injury.” from the report
Person-centred care
People appeared happy, and inspectors saw staff provide care in a person-centred way. Relatives said staff understood the people they supported.
“People's relatives told us they felt staff were very person centred” from the report
Infection control
seriousSome staff did not use PPE correctly. Visitor screening and track and trace recording were not consistent, so inspectors asked for closer monitoring.
“The service was not robustly preventing and controlling the spread of infection.” from the report
Visitor screening
seriousStaff had to be prompted to screen visitors when they arrived. Track and trace information was not consistently collected.
“Visitors were not consistently screened for COVID-19 on arrival to the service and "track and trace" information was not obtained” from the report
Training records
minorThe training matrix was not always up to date, and records showed that only a minority of staff had received recorded hand-hygiene training.
“The provider's own training matrix had not always been updated to reflect this.” from the report
- 01What checks are now in place to make sure all staff use PPE correctly every time?
- 02How do you screen visitors for COVID-19 and record track and trace information?
- 03How do managers check that care plan audits identify every shortfall and that problems are corrected?
- 04How up to date is the staff training matrix, particularly for hand hygiene and infection control?
- 05What improvements have been made since the last inspection, when Regulation 17 was breached?
This was a planned focused inspection of Safe and Well-led only; ratings for Effective, Caring and Responsive were carried over from previous comprehensive inspections. This explanation was written from the published report of 30 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.
What inspectors found, December 2019
Rated Requires Improvement; inspectors found kind, person-centred care, but concerns about medicines, staffing, the building and management checks.
This was an unannounced inspection on 12 November 2019. The inspector spoke with five people, seven staff members and reviewed care records, medicine records, staff files and management records.
The home was rated Good for Effective, Caring and Responsive care. People had personalised care plans, access to health professionals and activities. Inspectors saw staff being kind, patient and respectful, and found that people's choices, privacy and dignity were supported.
The home was rated Requires Improvement for Safe and Well-led care. Inspectors found medicines were not always managed safely, staff raised concerns about staffing levels, some recruitment checks were incomplete and parts of the flooring and other areas were worn. Management audits had missed some problems, and incidents that should have been reported to CQC had not been reported.
Personalised care
Care plans reflected people's needs, choices and preferences. Inspectors saw staff responding to people appropriately.
“The provider ensured people received person centred care which met their needs and took into consideration their wishes.” from the report
Kind and respectful staff
Inspectors saw staff treating people with kindness and respect. People were supported to make decisions about their care and daily choices.
“We observed staff interacting with people and found they were respectful and caring.” from the report
Activities and communication
An activity co-ordinator provided social activities, and information about people's communication needs was included in care plans.
“The service had an activity co-ordinator who provider social activities for people.” from the report
Risk assessments
The home had risk assessments for issues including falls, malnutrition and choking. Personal emergency evacuation plans recorded the help people would need.
“Risk assessments were in place to ensure hazards in relation to people's care had been considered and minimised.” from the report
Medicine management
seriousMedicine records did not always match the tablets left. Some as-needed medicines lacked protocols, some creams lacked body maps and medicine storage temperatures were not recorded.
“The provider did not always ensure medicines were managed safely.” from the report
Staffing and recruitment
seriousStaff said there were not always enough people on duty to meet residents' needs. One of the two recruitment files checked had only one reference.
“Staff raised concerns in relation to staffing. They felt there were not always enough staff to meet people's needs.” from the report
Worn parts of the building
needs fixingFlooring in the sluice room, downstairs toilet and dining area was worn. Some surfaces could not be cleaned effectively.
“The sluice room flooring was worn and had a split in it preventing it to be cleaned effectively.” from the report
Weak management checks
seriousAudits had not identified several problems found by inspectors. Two incidents and a safeguarding concern that should have been reported to CQC were missed.
“Systems in place to monitor the service were not always effective.” from the report
Dining experience
minorPeople were not always offered meal choices. The displayed menu did not match the food served, and using an ordinary trolley increased the risk of food becoming cold.
“We observed the dining experience during lunch and found this could be improved.” from the report
- 01How are medicines now checked so that medicine records match the medicines given?
- 02How do you decide how many staff are needed on each shift, taking account of the building's layout and residents' needs?
- 03Have recruitment checks, including references, been completed for all staff?
- 04How do you now make sure audits identify problems with medicines, infection control, staffing and the building?
- 05What action was taken after the two incidents and the safeguarding concern that were not reported to CQC?
This was an unannounced planned inspection covering all five CQC questions, with the overall rating and each key-question rating assessed during the visit. This explanation was written from the published report of 12 December 2019 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 Ashton Court Residential Home
4 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- January 2021Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Ashton Court Residential Home →
- December 2019Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at Ashton Court Residential Home →
- May 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- August 2014
Report published without a new overall rating.
- April 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- December 2012
Registered with the Care Quality Commission on 21 December 2012.
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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