CQC report explained · a residential care home
What the CQC found at Ashurst
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, September 2023
Ashurst rated Good overall, but inspectors found weaknesses in medicines records, staff induction records and management checks.
Inspectors visited on 23 August 2023 and reviewed further information up to 8 September. They spoke with people and staff, checked care and medicines records, reviewed six staff files and examined audits, incidents and other records.
The home was rated Good for Safe and Effective. People were supported by staff who understood their needs and encouraged independence. Inspectors found safe staffing, suitable safeguarding arrangements, timely healthcare support and person-centred care.
Well-led was rated Requires Improvement. Medicines were generally given safely, but records and stock balances were not always accurate. Staff induction records also had significant gaps, and some management audits did not identify the problems inspectors found.
The overall rating stayed Good because the inspection was focused on Safe, Effective and Well-led. Caring and Responsive were not inspected, so their previous ratings were carried forward.
Promoting independence
Staff understood how to support people to work towards their goals and make choices. People could personalise their rooms and had a budget to help decide how they were decorated.
“People were supported by staff who had a strong understanding of how to promote people's independence.” from the report
Safeguarding and staffing
Staff understood how to report safeguarding concerns. Inspectors found enough suitably checked staff to meet people's needs.
“There were enough safely recruited staff to support people.” from the report
Person-centred support
Care plans included people's preferences, needs and protected characteristics. People were involved in reviews and decisions about their care.
“The provider ensured a person centred approach to care planning, support and care was promoted throughout the service.” from the report
Healthcare access
The home sought help from external professionals promptly when people needed it, including from GPs, social workers and other professionals.
“When people required support with accessing external professional involvement this was requested in a timely manner.” from the report
Positive culture
People and staff gave positive feedback where inspectors were able to obtain it. Records showed that staff respected people's choices and supported people to remain in control of their care.
“There was a positive staff culture at the service which supported good outcomes for people.” from the report
Medicine records
needs fixingRecords did not always show correctly when people declined medicines. Stock balances were sometimes wrong, including one occasion when 50 more tablets were present than the records stated.
“Medicines were generally managed safely and people received their medication as prescribed. However, records relating to the administration of people's medicines were sometimes completed inconsistently.” from the report
Induction records
needs fixingStaff induction and medication assessment workbooks had significant gaps. Inspectors recommended that these records be completed consistently.
“We found staff had completed their training programme; however, staffs induction booklets contained significant gaps.” from the report
Management audits
needs fixingSome audits had identified issues but did not consistently reflect what inspectors found. This meant checks had not been effective in the areas of medicines and staff induction.
“We found gaps across induction and development records at this inspection. The service audits had not identified this issue consistently.” from the report
- 01What changes have been made to ensure medicine administration records are completed correctly when someone declines a medicine?
- 02How are medicine stock balances now checked, and how would you investigate a difference such as 50 extra tablets?
- 03Have all staff induction and medication assessment records been completed and checked?
- 04How do managers test that their audits accurately reflect what is happening in the home?
- 05Which current ratings for Caring and Responsive were carried forward from the previous inspection?
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 26 September 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, June 2022
Previous overall rating Good; a targeted inspection found staffing disruption and management pressures, but risks and care arrangements were being managed.
This was an unannounced, targeted inspection on 8 June 2022. Inspectors spoke with three young people and eight staff. They reviewed care plans, management records and policies, and observed a staff handover, a keyworker meeting and daily interactions.
The inspection followed concerns about staffing, training, risk management and governance. Several staff, including the registered manager, had left. The home was using regular agency and bank staff while recruiting, and an acting manager was overseeing the home with senior management support.
Inspectors found detailed risk assessments, regular reviews and good involvement of young people in their care. Training and induction arrangements were in place, infection prevention measures were satisfactory, and audits and incident reviews were being used to improve the service.
The home was inspected but not rated at this visit. Its previous overall rating was Good, published on 7 January 2022, and the report says that rating remained Good. A targeted inspection does not reassess every part of the service.
Detailed risk planning
Risks were assessed in detail, including triggers and early warning signs. Plans were reviewed regularly and young people were involved in their care.
“Risk assessments were very detailed and included triggers and early warning signs for staff to be aware of.” from the report
Training and induction
The home had a thorough induction, shadowing and ongoing training programme. Records showed staff had completed the training required by the provider.
“Staff reported a thorough induction process was in place, which included appropriate training and shadowing of experienced staff.” from the report
Clinical support
Residential and clinical staff shared information about incidents and new risks. Staff could contact clinical staff quickly when needed.
“There were regular discussions and updates between clinical and residential staff to help ensure all were aware of any incidents, new risks or changes.” from the report
Quality monitoring
The provider used audits, governance reports and monthly reviews of incidents to identify patterns and actions for improvement.
“All incidents were documented, monitored and analysed on a monthly basis to look at individual and general patterns and trends.” from the report
Inconsistent staffing
needs fixingSeveral staff had left, including the registered manager and deputy manager. The home used agency and bank staff while recruiting, and young people and staff noticed the lack of a consistent team.
“The young people felt a little unsettled due to the lack of a consistent, permanent staff team.” from the report
No registered manager
needs fixingThere was no registered manager in post during the inspection. An acting manager and senior management team were covering while recruitment took place.
“At the time of our inspection there was not a registered manager in post.” from the report
Communication and supervision
needs fixingSome staff said communication with management was an issue. Supervisions had restarted but could be cancelled or provided by different supervisors.
“Staff supervisions had been resumed, but were sometimes cancelled when there were other priorities.” from the report
Staff pressure
needs fixingStaff said they felt overwhelmed, and some described burnout while the home was trying to build a full and consistent team.
“However, they were feeling overwhelmed and looking forward to having a full and consistent staff team in the future.” from the report
- 01Has a registered manager now been appointed, and who is responsible for the home until that happens?
- 02How many permanent staff are now in post, and how often is the home using agency or bank staff?
- 03How are you making sure young people have a consistent staff team?
- 04How are staff supervisions and communication with management being kept regular?
- 05What changes have been made to staff training and support after incidents?
This was a targeted inspection of concerns about staffing, training, risk management and governance, with infection prevention and control also checked; it did not assess every part of the five key questions, so the previous Good ratings carried over. This explanation was written from the published report of 29 June 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 Ashurst
2 rated inspections over 2 years: the service has held its Good rating throughout.
- September 2023Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2022Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- January 2022GoodSafe: GoodEffective: GoodWell-led: Good
- March 2021
Registered with the Care Quality Commission on 30 March 2021.
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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