CQC report explained · a residential care home
What the CQC found at Ashurst Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- People received their medicines and staff understood people's risks, but some written instructions and risk assessments lacked important detail. Inspectors also found an incomplete recruitment record, an unrestricted skylight that was fixed promptly, and kitchen hygiene problems.
- Effective?
- Good
- Staff had the skills and support they needed, and people received help with healthcare, food, exercise and healthy living. Some care plans did not clearly record advice about weight loss or exercises.
- Caring?
- Good
- Staff were empathetic and treated people with respect. People were involved in decisions, supported to be independent, and helped to maintain their privacy and dignity.
- Responsive?
- Good
- Care plans were personalised and regularly updated, and people were supported with activities, relationships, cultural needs and community links. Daily records did not always show whether planned tasks had been completed.
- Well-led?
- Good
- Managers were visible, approachable and open to feedback. Audits and improvement systems were in place, although inspectors said checks needed to identify some minor record-keeping, recruitment and hygiene issues more reliably.
What inspectors found, November 2021
Ashurst Lodge was rated Good overall, but inspectors found limited assurance about safety and asked for improvements to medicines and care records.
This was the first inspection since registration. It was unannounced and took place on 14 September 2021. One inspector spoke with people, staff and managers, and reviewed care records, medicines records, recruitment files, cleaning checks, audits and other documents.
People generally described the care positively. Staff were kind, respectful and supportive. Inspectors found that people were involved in their care, encouraged to be independent, supported with their health and social needs, and able to raise complaints.
The main weaknesses were under Safe. PRN medicines instructions did not include enough detail, some risk assessments did not explain clearly how risks should be managed, one recruitment file was incomplete, and kitchen cleaning needed improvement. One window safety problem was fixed immediately. The home received Good ratings in Effective, Caring, Responsive and Well-led, but Requires Improvement for Safe.
Kind and respectful staff
People said staff were kind and caring. Inspectors saw staff listening to people, offering emotional support and helping them feel valued.
“Staff are kind and caring. I get on well with all of them” from the report
Promoting independence
The home supported people to do as much as possible for themselves and to work towards living outside a care home. This included cooking, managing money and making everyday choices.
“The service had a strong ethos of promoting independence and allowing people the freedom to do as much for themselves as possible.” from the report
Personalised support
People helped create and review their support plans. Plans included individual needs, preferences, social interests, cultural needs and goals.
“People's care and support was planned to meet their needs in an empowering way.” from the report
Open management
People and staff felt able to speak up. Managers used meetings, keyworker sessions and surveys to gather views and make changes.
“The service had an open and inclusive culture.” from the report
Learning from incidents
The provider recorded incidents, acted to reduce the chance of repeat problems and worked with mental health services to share learning.
“There was evidence of lessons learned and changes made to people's risk management plans as a result.” from the report
PRN medicine instructions
needs fixingInstructions for medicines given only when needed did not clearly state what they were for, the maximum dose or exactly when to give them. Inspectors recommended that the protocols be updated.
“There was a small risk that they would not be administered safely because records lacked information about maximum dosages and a written confirmation they were only to be given to people who asked for them.” from the report
Risk assessments lacked detail
needs fixingSome written assessments did not explain warning signs, triggers or the action staff should take. Staff understood people's risks, but written information might not have been enough for staff who did not know people well.
“Each risk had a score of low, medium or high. However, it was not clear what this score meant or what measures were in place to reduce risks.” from the report
Kitchen hygiene
needs fixingInspectors found crumbs in the fridge and freezer and cooked food left out overnight. The manager addressed this immediately and said a stronger night cleaning routine would be introduced.
“We identified an issue around kitchen hygiene as there were crumbs visible inside the fridge and freezer and some cooked food had been left out overnight.” from the report
Care plans did not always record health advice clearly
needs fixingStaff knew people's health needs, but some plans did not clearly record agreed weight-loss targets or exercises recommended by health professionals. Inspectors recommended clearer support plans.
“However, care plans did not always show clearly how this was done.” from the report
Incomplete recruitment record
minorOne staff file did not contain a full employment history and had unexplained gaps. The manager said the missing information would be obtained.
“One staff file did not contain a full history of employment since leaving school as there were unexplained gaps in this.” from the report
- 01Have the PRN medicine protocols been updated to state what each medicine is for, the maximum dose and when it should be given?
- 02Have risk assessments been rewritten to explain warning signs, triggers and the action staff should take?
- 03Has the new care records system been introduced, and does it record daily support and advice from health professionals?
- 04What checks are now in place to make sure the kitchen is cleaned properly and food is stored safely overnight?
- 05Has the missing employment history in the staff recruitment file been completed?
This was an unannounced first inspection covering all five key questions, including infection prevention and control measures; there was no previous rating to carry over. This explanation was written from the published report of 11 November 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 Ashurst Lodge
Each visit the CQC has published, newest first, back to the day the home was registered.
- November 2021Goodcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2020
Registered with the Care Quality Commission on 29 January 2020.
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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