CQC report explained · a residential care home
What the CQC found at Ashville House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found environmental risks, incomplete records about food, fluids and weights, and insufficient analysis of falls. Medicines, recruitment, cleanliness and equipment maintenance were found to be safe.
- Effective?
- Good
- Staff were trained and supported, people had access to health professionals, and the food was balanced. Inspectors still had concerns about recording and evaluating people's food and fluid intake.
- Caring?
- Good
- Staff knew people well, treated them respectfully and supported their dignity, independence and choices. People were offered exercise, social opportunities and support based on their preferences.
- Responsive?
- Good
- Care plans described people's needs and preferences. The home provided many activities, supported people's wishes about future care, and responded to complaints and feedback.
- Well-led?
- Requires improvement
- The home was positive and inclusive, but management oversight did not always identify and reduce risks quickly enough. Records and audits did not always show clearly whether people received the care they needed.
What inspectors found, March 2019
Rated Requires Improvement; inspectors found kind, active care but weaknesses in safety checks, nutrition records and management oversight.
Inspectors made an unannounced visit on 29 January 2019. They spoke with people living in the home, relatives and staff, observed care, and checked care plans, staff records and management records.
The home was clean and comfortable. Staff were kind, respectful and trained. People had access to medicines, health professionals, food, activities and support to stay active. The home listened to complaints and feedback.
Improvements were needed in how risks were managed and recorded. Inspectors found incomplete food, fluid and weight records, limited analysis of falls, and some environmental risks. Some people also said call bells could take 10 to 15 minutes to answer at busy times.
The overall rating was Requires Improvement. Safe and well-led were Requires Improvement, while effective, caring and responsive were Good. The home had been rated Good at the previous inspection in June 2016. There were no breaches of regulations.
Kind and respectful staff
People said staff treated them well. Inspectors saw staff speaking respectfully, protecting privacy and supporting people's dignity.
“The carers are lovely and have made me feel at home very quickly.” from the report
Activities and engagement
The home offered regular exercises, music, outings, quizzes, crafts and other activities. Inspectors saw people taking part and enjoying themselves.
“Activities were very well attended and engaged people well.” from the report
Medicines managed safely
Inspectors found clear medicine records, suitable storage and competent administration. Staff waited with people while they took their medicines.
“We observed medicine administration and this was done correctly and safely by competent staff.” from the report
Clean and well-maintained surroundings
The home was described as clean, spacious, comfortable and homely. Infection control practices were good.
“The service was clean, spacious and laid out in a way which enabled people, staff and visitors to have private space.” from the report
Incomplete food and fluid records
needs fixingRecords did not always show what people had eaten or drunk, or whether they had reached their needs. This made it difficult to identify and respond to risks of dehydration or malnutrition.
“These were not fully completed and did not always show the amount people had eaten making evaluation difficult.” from the report
Weight and nutrition monitoring
needs fixingSome people had lost weight, and records did not always show regular weighing or clear actions to reverse weight loss. The weighing scales had also been broken for a period.
“We were concerned from the records viewed that people were not always weighed monthly and a reduction in weight was not being identified quickly enough.” from the report
Environmental and falls risks
seriousInspectors found a hot, uncovered radiator, poorly marked changes in floor level and gaps in handrails. A recent serious fall had not led to immediate action to address the sloped floor.
“No immediate actions had been taken following this incident and this must be reviewed urgently.” from the report
Limited analysis of incidents
needs fixingAlthough falls, accidents and incidents were recorded, the home did not always analyse them well enough to identify patterns or lessons.
“We found however when falls did occur there was insufficient analysis of them to ascertain if there was any specific patterns or reasons for a spike in falls.” from the report
Call bell delays at busy times
needs fixingSeveral people said staff could be rushed and call bells were not always answered quickly when the home was busy.
“You sometimes have to wait 10/15 minutes for your bell to be answered but they have so many other people to attend to as well.” from the report
Care records not always reliable
needs fixingStaff did not always update care plans or write the daily notes about care they had delivered. Inspectors could not be sure that records accurately reflected the care provided.
“This meant information could get lost in translation and we could not be assured of the accuracy of recording.” from the report
- 01What new system is now used to record and review food and fluid intake for people at risk of dehydration or malnutrition?
- 02How often are residents weighed, and what action is taken if someone loses weight?
- 03How are falls analysed now, including falls linked to the sloped flooring?
- 04What has been done to improve call bell response times during busy periods?
- 05How does the manager check that daily records accurately show the care staff have provided?
This was an unannounced inspection covering all five CQC questions, including both the care provided and the home's premises. This explanation was written from the published report of 12 March 2019 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 Ashville House
2 rated inspections over 3 years: the service has slipped, from Good to Requires improvement.
- March 2019Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 5 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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13 live-in carers within about an hour of Norfolk
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 £990 to £1,120 a week. 9 can care for a couple. 14 years' experience on average.
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.