CQC report explained · a residential care home
What the CQC found at Ashview House Residential Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks, medicines, recruitment and infection control were managed safely. Some risk management plans needed further updates, but these were corrected immediately.
- Effective?
- Good
- People's needs and preferences were assessed and recorded. Staff were trained, people received suitable food and healthcare, and consent arrangements were handled in line with the law.
- Caring?
- Good
- This key question was not inspected during this focused visit.
- Responsive?
- Good
- This key question was not inspected during this focused visit.
- Well-led?
- Good
- Inspectors found improved leadership, clearer staff responsibilities and stronger quality checks. The management team acted on shortfalls and involved relatives, staff and other professionals.
What inspectors found, April 2022
Ashview House Residential Care Home is rated Good; inspectors found safer, more effective care and better management, with some staffing views differing.
This was an unannounced focused inspection on 14 and 17 March 2022. Two inspectors and an Expert by Experience spoke with people, relatives and staff. They also reviewed care records, medicines records, recruitment files, training information and management records.
The home was rated Good for Safe, Effective and Well-led. Inspectors found that risks and medicines were managed safely, infection control arrangements were suitable, staff were recruited and trained safely, and people received appropriate food and healthcare. Some risk plans needed updating, but these were corrected immediately.
The home had improved since its previous inspection, which was rated Requires Improvement and found breaches of regulations. Inspectors found that the previous breaches had been addressed and that the home was no longer in breach. This inspection did not assess Caring or Responsive, so those areas were not newly rated in this report.
Safer medicines
Medicines management had improved. Inspectors saw people receiving medicines safely and on time, with records matching the medicines checked.
“We observed people receiving their medicines on time and in a safe way.” from the report
Personalised support
Care plans recorded people's needs, wishes and preferences. Staff were observed supporting people in line with those plans.
“Records viewed indicated people's needs, wishes and preferences and we observed staff supporting people in line with their care plans.” from the report
Food and health support
Dietary preferences were met, including cultural and vegetarian needs. Other health professionals were involved when people needed specialist advice.
“Where necessary, relevant professionals, such as speech and language therapists and dieticians were consulted to obtain additional clinical advice to support people in the most effective way.” from the report
Improved management
The home had introduced new care planning and quality monitoring systems. Relatives and professionals reported noticeable improvements since the previous inspection.
“The provider and management team had worked to create a positive culture and improve standards of care across the home.” from the report
Risk plans needed updating
needs fixingInspectors found that some risk management plans were not fully up to date. The manager was told about this and corrected the plans immediately.
“People's risks were assessed, and plans were put in place to mitigate the risk of harm to people, however we did identify some risk management plans needed further updates.” from the report
Mixed views about staffing
minorThe provider's staffing calculation indicated that numbers and skills matched people's needs. However, some staff and relatives thought people would benefit from more staff on shift.
“Some staff and relatives felt there were sufficient numbers of staff, whilst others expressed, they felt people would benefit from increased numbers of staff on shift.” from the report
- 01How many staff are normally on each shift, and how do you respond when people need more support?
- 02How often are each person's risk assessments and management plans reviewed and updated?
- 03How will you check that the improvements made since the previous inspection continue over time?
- 04How are relatives involved in reviewing care plans and raising concerns about care or staffing?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and the overall rating also used earlier ratings for areas not covered. This explanation was written from the published report of 14 April 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, June 2021
Rated Requires Improvement; inspectors found risks with medicines, care planning, dietary needs and management, and issued warning notices.
This was an unannounced focused inspection on 24 May 2021. Inspectors spoke with people, relatives and staff, observed care, and checked care, medicine, staffing and management records. They also checked infection control arrangements.
The home was not always safe or effective. Medicine records and storage checks were incomplete. Risks, health needs and care plans were not always clearly recorded or followed. Some people's dietary choices and health needs were not consistently met.
Inspectors also found weaknesses in consent records and quality checks. The home had a registered manager, staff understood safeguarding, people had access to healthcare, and relatives generally spoke positively about the manager and staff.
The overall rating fell from Good at the previous comprehensive inspection to Requires Improvement. This means inspectors found important improvements were needed, although they found no evidence that people had been harmed.
Safeguarding
Staff had safeguarding training and knew how to report concerns. Safeguarding concerns had been passed to the appropriate authorities in a timely way.
“Staff had received safeguarding training and understood how to keep people safe from the risk of abuse.” from the report
Healthcare support
Records showed people attended health appointments and received visits from healthcare professionals. Relatives were generally satisfied with support for health needs.
“The registered manager worked with other agencies and professionals to ensure people received timely support.” from the report
Infection control
Inspectors were assured about infection prevention, testing, protective equipment, visiting arrangements and outbreak planning.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Staff support
Staff received induction and mandatory training, and the training system identified refresher training. Staff said they felt supported.
“There was a registered manager in place and staff told us they felt supported in their work.” from the report
Positive relationships
People and relatives said they felt safe and spoke positively about the manager. Staff were described as open to improvement.
“People, staff and relatives spoke positively about the registered manager and felt they were committed to making improvements across the home.” from the report
Medicines
seriousMedicine administration records were incomplete. Guidance for some medicines was missing, and checks on storage temperatures were inconsistent.
“Medicines were not always stored, administered and recorded in a safe way.” from the report
Risk and care planning
seriousSome risks, health conditions and wound care needs were not clearly assessed or planned for. Care plans were not always followed, creating a risk of inconsistent care.
“Information contained in people's care plans was not always followed meaning that people received inconsistent care that posed a risk to their health and well-being.” from the report
Dietary needs
needs fixingA person who had identified as vegetarian was given a meal containing turkey. Records also contained conflicting dietary information and staff did not always know people's nutritional health needs.
“During our inspection, we observed one person who had identified as a vegetarian, be given a turkey dinner.” from the report
Consent records
seriousSome records did not show that mental capacity had been assessed properly. Relatives had signed some consent records without evidence of legal authority to do so.
“Some records we viewed had been signed by relatives authorising consent but there was no documentation to evidence the legal authorisation to do so.” from the report
Quality checks
seriousAudits were not always completed, and identified problems did not always have an action recorded. This meant the home could not reliably show that risks were being addressed or lessons learned.
“The quality and safety assurance processes were not always effective in identifying and addressing risk in a timely way.” from the report
Staffing levels
needs fixingInspectors saw people waiting for support. The provider was asked to review dependency scores to check that staffing levels matched people's needs.
“We recommend the provider reviews all dependency scores for people living at Ashview House so this can be measured against the staffing dependency tool.” from the report
- 01What changes have been made to ensure every medicine is stored, administered and recorded safely?
- 02How are care plans and risk assessments now checked so staff follow them consistently, including for diabetes, wounds and other specific health needs?
- 03How do you make sure each person's dietary choices and nutritional needs are recorded accurately and followed at every meal?
- 04How are mental capacity assessments, best-interest decisions and consent from relatives recorded and reviewed?
- 05What action has been taken in response to the warning notices, and what evidence can you show that the changes are working?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and previous ratings for those questions carried over. This explanation was written from the published report of 24 June 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 Ashview House Residential Care Home
12 rated inspections over 7 years: the service has improved, from Inadequate to Good.
- April 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Ashview House Residential Care Home →
- June 2021Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
Read what inspectors found at Ashview House Residential Care Home →
- October 2019Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- November 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2018Requires improvementup from InadequateSafe: Requires improvementWell-led: Requires improvement
- March 2018Inadequatestayed InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- November 2017Inadequatestayed InadequateSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- February 2017Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- May 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2016Requires improvementup from InadequateSafe: Requires improvementEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2016Inadequatestayed InadequateSafe: InadequateEffective: InadequateCaring: InadequateResponsive: Requires improvementWell-led: Inadequate
- June 2015InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- December 2014
Registered with the Care Quality Commission on 1 December 2014.
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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