CQC report explained · a residential care home
What the CQC found at Ashview
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, August 2023
Rated Inadequate and placed in special measures; inspectors found serious risks in safety, staffing, care planning and management.
The home provides personal care for up to 13 people with learning disabilities and autistic people. Twelve people lived there during the inspection. Inspectors visited unannounced on 31 May and 6 June 2023. They spoke with people, relatives and staff, observed care, and checked care, medicines, staffing and management records.
Inspectors found widespread problems. Risks to people's health and safety were not always assessed or managed. Medicines records were incomplete, safeguarding systems were weak, staff training and supervision were not good enough, and people's nutritional needs were not always monitored. Care plans often did not reflect people's needs, choices, goals or preferences.
The home was rated Inadequate overall. Safe, Effective and Well-led were rated Inadequate. Caring and Responsive were rated Requires Improvement. The home had previously been rated Requires Improvement in July 2022, but inspectors found that the provider remained in breach of regulations and had not made enough improvement.
Safe recruitment
The home completed appropriate checks before staff started work.
“The provider had processes in place to recruit staff safely and appropriate checks were completed prior to staff starting their employment.” from the report
Some kind interactions
Inspectors saw some staff give kind and compassionate care. People who could speak with inspectors said they felt comfortable talking to staff and raising concerns.
“We observed some staff providing kind and compassionate care and interacting with people in a positive way which showed genuine interest in their well-being.” from the report
Family contact
Relatives said people were supported to stay in contact with friends and family through visits and phone calls.
“People were supported to stay in contact with friends and family.” from the report
Specialist support
People received support from relevant health professionals for eating and drinking needs when this was needed.
“People received specialised support from the relevant health professionals to support their eating and drinking needs when necessary.” from the report
Risks and medicines
seriousHealth risks were not always updated after people's needs changed. Medicines records did not always show why or when medicines were given, creating a risk of pain or inappropriate administration.
“The provider had not effectively managed risks to people's health and safety or ensured safe medicines processes were in place.” from the report
Safeguarding and incidents
seriousSafeguarding concerns and incidents were not recorded or investigated well enough. The home could not show that it consistently learned from what went wrong.
“The provider did not have effective systems in place to safeguard people from the risk of abuse.” from the report
Staff skills
seriousNot all staff had suitable training or knowledge about supporting people with learning disabilities and autistic people. Supervision was not regular and agency staff inductions were incomplete or out of date.
“The provider had failed to ensure staff were suitably qualified, competent, skilled and experienced.” from the report
Care choices and dignity
seriousCare plans did not give enough information about people's needs, preferences and goals. Inspectors saw people being given tasks without clear choices, and language used about some support needs was not respectful.
“The provider had not ensured people were always supported in a dignified and respectful way.” from the report
Food and drink records
seriousMeals and snacks did not always have enough variety. Records did not consistently show how much people ate or drank, or whether concerns had been acted on.
“The provider had not reviewed people's nutritional and hydration needs to ensure their needs were met.” from the report
Environment and infection control
needs fixingSome equipment was stored outside and uncovered, and communal surfaces were worn. Not all staff had up-to-date infection prevention and control training.
“We were not assured this equipment was kept hygienically clean and ready for use due to it being uncovered and left outside for prolonged periods.” from the report
- 01What has changed since the inspection to make sure health risks and medicines records are assessed, updated and checked?
- 02How do you now ensure all permanent and agency staff have the right training, induction and regular supervision?
- 03How are people and their relatives involved in writing and reviewing care plans, goals and decisions about who they live with?
- 04How do you monitor meals, snacks, food and fluid intake, and act quickly when there are concerns?
- 05What evidence can you show of progress against the warning notices and the plan to leave special measures?
This was an unannounced follow-up inspection that assessed all five key questions, as well as infection prevention and control and the Right support, right care, right culture principles. This explanation was written from the published report of 17 August 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, July 2022
Requires Improvement; inspectors found risks from incomplete staff training, medicines records and weak checks on quality.
This was an unannounced focused inspection on 13 and 17 June 2022. Two inspectors and an Expert by Experience spoke with people, relatives, staff and professionals, observed care and checked care, medicines, recruitment and management records.
The home was not always safe. Staff training was incomplete, some recruitment references had not been checked properly, and medicines and risk records were not always up to date. Infection control had improved, and the home responded promptly to some concerns found during the visit.
The home was not well-led because its checks had failed to find problems with training, medicines and records. The overall rating remains Requires Improvement. The home had also been rated Requires Improvement at the previous inspection, so it has had this rating for two consecutive inspections.
Safeguarding
Staff knew how to recognise abuse and how to report concerns. Managers investigated incidents and shared lessons with staff.
“Staff recognised incidents and reported them appropriately and managers investigated incidents and shared lessons learned.” from the report
Choice and independence
People were involved in decisions about their care and safety. Staff supported people to make choices about their medicines and encouraged independence.
“People were supported to make decisions and staff communicated with people in ways that met their needs.” from the report
Infection control improvements
The home had improved its infection prevention processes. It increased cleaning, used protective equipment appropriately and updated its outbreak plans.
“The provider had made improvements to their infection prevention and control processes and people were now protected from the risk of infection.” from the report
Supportive staff culture
Staff said they could raise concerns without fear and felt supported and valued by managers.
“Staff felt able to raise concerns with managers without fear of what might happen as a result.” from the report
Incomplete staff training
seriousNot all staff had completed mandatory training, including moving and handling, safeguarding, infection control and food hygiene. Inspectors said this created a risk that staff might not know how to support people safely.
“The provider had failed to ensure staff received appropriate training.” from the report
Weak quality checks
seriousThe provider's audits did not identify important problems with training, medicines and out-of-date documentation. This was a continued breach of Regulation 17.
“Robust systems were not in place to monitor the quality and safety of the service.” from the report
Medicines records
needs fixingSome medicines care plans and risk assessments had not been reviewed, and an error on one medicines administration record had not been found by the home's audits.
“The provider had not always ensured the documentation in people's medicines folders was up to date and reflected their current support needs.” from the report
Care plans and activities
needs fixingPeople did not always have meaningful, person-centred activities. Care records did not always show people's current goals, preferences and progress.
“People lacked meaningful, person-centred activities and there was a lack of documentation to evidence how people were being supported to achieve the goals set in their care plans.” from the report
Recruitment checks
needs fixingThe home had recruitment processes, but applicants' references were not always checked or verified in line with best practice.
“Applicant's references were not always checked or verified in line with best practice.” from the report
- 01How have you made sure every member of staff has completed the required training, and how do you check that their skills remain current?
- 02How are medicines records, administration records and competency assessments now checked for errors and kept up to date?
- 03How often are care plans and risk assessments reviewed, including plans for emergency epilepsy medicines?
- 04What meaningful activities are available for my relative, and how will you record progress towards their personal goals?
- 05What changes have you made to your quality checks so that problems are found and corrected promptly?
This was a focused inspection of Safe and Well-led; the other key question ratings were carried over from the previous inspection. This explanation was written from the published report of 21 July 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 Ashview
5 rated inspections over 8 years: the service has slipped, from Good to Inadequate.
- August 2023Inadequatecurrent ratingdown from Requires improvementSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- July 2022Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- March 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- January 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 25 November 2010.
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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35 live-in carers within about an hour of Essex
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Most charge £1,020 to £1,260 a week. 25 can care for a couple. 10 years' experience on average.
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