CQC report explained · a nursing home
What the CQC found at Ashurst Mews Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risk management had improved, but records of repositioning, support for people with diabetes and environmental safety checks still needed improvement. Staffing feedback was mixed, with relatives raising concerns and high use of agency staff.
- Effective?
- Requires improvement
- This question was not inspected during this focused inspection. Its previous rating was carried forward.
- Caring?
- Requires improvement
- This question was not inspected during this focused inspection. Its previous rating was carried forward.
- Responsive?
- Requires improvement
- This question was not inspected during this focused inspection. Its previous rating was carried forward.
- Well-led?
- Requires improvement
- Management systems had improved but were not fully embedded. There was no registered manager in post, and oversight did not consistently cover all areas of people's care.
What inspectors found, September 2022
Rated Requires Improvement; inspectors found improvements, but risks, staffing consistency and management oversight still needed attention.
This was an unannounced focused inspection. Inspectors visited on 3 August 2022 and continued inspection activity until 9 August. They looked only at Safe and Well-led, following safeguarding and leadership concerns.
The home had improved since the previous inspection and was no longer in breach of regulations. However, inspectors still found gaps in records about repositioning, diabetes support and environmental checks. Relatives also raised concerns about staffing levels and the use of agency staff.
Medicines, infection control, recruitment and safeguarding arrangements were found to be satisfactory. However, there was no registered manager in post, and inspectors found that management oversight did not yet consistently identify or address all risks.
The overall rating remains Requires Improvement. It has held this rating for the last two consecutive inspections. The ratings for Effective, Caring and Responsive were carried forward from the previous inspection because they were not inspected this time.
Medicines
Medicines were administered by trained staff. An electronic system helped reduce the risk of errors.
“The provider used an electronic medicines administration system which minimised the risk of medicines errors and ensured people received their medicines as prescribed.” from the report
Infection control
Inspectors were assured about infection prevention, personal protective equipment and the home's response to infection risks.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Recruitment
Recruitment checks were completed before staff started work, including criminal record checks and employment references.
“Staff were checked for any criminal convictions and satisfactory employment references were obtained before they started to work at the home.” from the report
Working with other services
The management team worked with local authority and healthcare services and followed advice about people's care.
“The management team worked well with other partnership agencies including the local authority and healthcare services.” from the report
Incomplete repositioning records
needs fixingSome people needed regular repositioning to protect their skin. Inspectors found that records in one area did not consistently show this support.
“However, improvement was required to records of repositioning in one area of the home” from the report
Support for people with diabetes
needs fixingPeople with diabetes did not always have enough choice of foods low in sugar. The manager agreed to review the food choices.
“improvements were required to the support in place for people with diabetes, to ensure they were offered sufficient choice of foods that were low in sugar.” from the report
Staffing consistency
needs fixingAlthough inspectors saw enough staff during the visit, relatives reported that staff were rushed or not visible. The home was using high numbers of agency staff.
“People's relatives did not feel there were enough staff, six out of seven relatives spoken with raised concerns about staffing levels.” from the report
Management oversight
needs fixingSafety and care monitoring systems had improved but needed to be embedded. Inspectors found that oversight did not cover all areas consistently.
“Further improvements were required to ensure effective oversight of all areas of people's care, for example records of repositioning and people's health needs.” from the report
No registered manager
needs fixingThere was no registered manager in post when inspectors visited. A new manager had been recruited but had not yet started.
“At the time of our inspection there was not a registered manager in post.” from the report
Personal care and advocacy
needs fixingOne person's dignity was not consistently upheld because the level of support needed with personal care had not been properly recognised. Not everyone who might benefit had access to advocacy services.
“There was a lack of oversight of the level of support required by one person to meet their personal care needs, which meant their dignity had not been consistently upheld.” from the report
- 01How are you checking that repositioning is carried out and recorded for every person who needs it?
- 02What low-sugar food choices are now available for people with diabetes?
- 03How many agency staff are currently being used, and how do you make sure they know each person's needs?
- 04Who is managing the home while there is no registered manager, and when is the new manager expected to start?
- 05What action have you taken to make sure personal care support consistently protects people's dignity and that suitable advocacy is offered?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried forward from the previous inspection. This explanation was written from the published report of 28 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, March 2022
Ashurst Mews Care Home was rated Requires Improvement; inspectors found staffing, risk management and oversight were not consistently safe.
This was an unannounced inspection on 25 and 30 November 2021. Inspectors spoke with people living in the home, relatives, staff and a visiting professional. They reviewed care, medicine and management records, and checked infection control.
The home was sometimes short staffed. People could wait too long for personal care, drinks, baths, showers or companionship. Risk assessments and safety checks were not always complete or acted on. Inspectors also found gaps in training, care records, falls monitoring and records for some medicines given when needed.
There were positive findings. The home was clean, staff used protective equipment correctly, and people were supported with healthcare, choices, privacy and dignity. However, all five areas were rated Requires Improvement, meaning care was not consistently safe, effective, caring, responsive or well-led.
The previous rating was Outstanding, published in October 2019. This inspection found that all five ratings had deteriorated to Requires Improvement. The CQC identified breaches relating to safe care, staffing and good governance, and planned to monitor improvements.
Clean environment
Inspectors found the home clean and without unpleasant smells. Relatives also spoke positively about its cleanliness.
“The home was clean and free from malodour.” from the report
Infection precautions
Staff used protective equipment appropriately and understood hand hygiene. Visitors were screened and tested before entering.
“We were assured that the provider was using PPE effectively and safely.” from the report
Respect and independence
People's privacy and dignity were respected. Staff supported people to do what they could for themselves.
“Independence was supported as much as possible.” from the report
Healthcare support
People were supported to access healthcare professionals, and records contained information to help with transfers to other services.
“People were supported to access healthcare services as and when required, such as GP's, district nurses and dietitians.” from the report
Open communication
The registered manager was described as available to meet families, and the service kept families informed when accidents or incidents happened.
“The registered manager had been open and transparent when things had gone wrong” from the report
Not enough staff
seriousThere were vacancies and staff shortages. People sometimes waited for personal care and staff could not always provide requested baths, showers or companionship.
“There were not always enough staff to meet people's needs.” from the report
Risks not consistently managed
seriousFire, water and equipment safety checks were not regular enough. Some falls risks and distress-related risks did not have clear guidance for staff.
“Environmental risks such as fire safety, water safety and safety of equipment had not consistently been monitored to mitigate risk.” from the report
Weak management checks
seriousAudits and daily checks failed to identify several problems with risk assessments, infection controls and care records.
“The provider's audits and quality checks failed to identify risk assessments did not identify all risks” from the report
Limited activities
needs fixingRecords showed limited entertainment and one-to-one activities. Inspectors found no evidence of activities or communal space being used on the nursing unit.
“Records reflected there was limited entertainment and one to one activity for people.” from the report
Training and hydration gaps
needs fixingSome staff training updates were overdue. Fluid records did not state how much some people needed to drink each day, although this was later corrected.
“Some staff were overdue training refreshers.” from the report
Incomplete care records
needs fixingSome care plans needed more detail, and records did not always show that people received support with oral and denture care.
“We found gaps in some people's care records and were not reassured that people were always helped with teeth brushing and denture care.” from the report
- 01What staffing levels are now in place on each unit, including evenings and weekends, and how do you calculate the number needed for residents' needs?
- 02How do you now check and record risks such as falls, fire safety, water safety and equipment safety?
- 03What action has been taken to complete overdue training and ensure all temporary staff have infection control training and recorded test results?
- 04How do you check that residents receive enough drinks, oral care, personal care and support with their individual preferences?
- 05What activities are now available for people with complex mobility or health needs, including those on the nursing unit?
This was an unannounced inspection covering all five key questions and infection prevention and control; the report says all five ratings had deteriorated from the previous inspection. This explanation was written from the published report of 10 March 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 Mews Care Home
4 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- September 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2022Requires improvementdown from OutstandingSafe: Requires improvementWell-led: Requires improvement
- October 2019Outstandingup from GoodSafe: GoodEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Outstanding
- March 2017GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2016
Registered with the Care Quality Commission on 14 March 2016.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
At least 100 live-in carers within about an hour of West Northamptonshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,280 a week. 87 can care for a couple. 12 years' experience on average.
“We can all fully relax around Nyarai and she feels like part of our family, which is no mean feat!”
“If you bump into her in the night on her way to the bathroom she will still inquire how you are and if everything is alright.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.