CQC report explained · a nursing home
What the CQC found at Ashwood Court Supportive Pathways
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- The home was clean and safe, had enough staff, and managed risks, safeguarding and medicines well. Inspectors noted that the female-only lounge was not always available for female patients.
- Effective?
- Good
- Staff completed physical and mental health assessments and used personalised, recovery-focused care plans. Inspectors found suitable treatments and specialist support, but did not see routine training in rehabilitation and recovery-focused practice.
- Caring?
- Good
- Patients told inspectors that staff were respectful, kind and available. Patients and families were involved in care planning and treatment decisions.
- Responsive?
- Good
- Discharge was planned carefully and patients were not discharged before they were ready. The home was still revising its admission, discharge and transfer procedures.
- Well-led?
- Good
- Inspectors found stronger leadership, auditing and oversight than at the previous inspection. However, some policies were incomplete and the home was continuing to review its procedures.
What inspectors found, October 2023
Rated Good and no longer in special measures; inspectors found safe, kind care after significant improvements.
This was an unannounced inspection on 20 and 21 June 2023. Inspectors spoke with patients, a carer, staff and other organisations. They observed care, checked the environment and medicines, and reviewed care records, staff files and service documents.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found clean and safe surroundings, enough staff, safe medicines processes, personalised care plans and kind support. Patients said staff were respectful, available and involved them in their care.
The rating had improved from the previous inspection in May 2022, when the home was rated Inadequate overall and placed in special measures. The warning notices about risk management and auditing had been complied with, and the home was no longer in special measures.
Safe surroundings
Inspectors found the wards clean, well maintained and fit for purpose. Staff carried out regular safety checks and updated environmental risk assessments.
“All wards were safe, clean well equipped, well furnished, well maintained and fit for purpose.” from the report
Personalised care
Care plans covered patients’ mental and physical health needs and supported recovery and independence. Patients were actively involved in preparing their plans.
“Care plans reviewed were recovery based and promoted independence.” from the report
Kind and respectful staff
Patients told inspectors that staff were kind, respectful and available when support was needed. Staff involved patients and families in care decisions.
“Patients told us staff were respectful and there for them.” from the report
Well-planned discharge
Staff worked with other services to plan discharge and aftercare. Inspectors found that discharge was rarely delayed for reasons other than clinical ones.
“As a result, discharge was rarely delayed for other than a clinical reason.” from the report
Improvement since 2022
The home had improved its risk assessments, care plans, incident reporting and audits. The earlier warning notices had been complied with.
“We found the Section 29 warning notices had been complied with.” from the report
Female-only lounge
needs fixingThe female-only lounge was also used for meetings and for the ward computer. It was available on request, but not always available exclusively for female patients.
“There was a female-only lounge, however, this was also used for meetings including multidisciplinary meetings” from the report
Incomplete policies
needs fixingInspectors said some policies still needed work and contained blank spaces. The provider was told to keep policies current and in line with national guidance.
“Some policies were incomplete, containing blank spaces for further amendment and inclusion of information.” from the report
Procedures still being revised
needs fixingAdmission, discharge and transfer procedures were being re-worked during the inspection. Policies were also being adapted to ensure transfer standards were followed.
“At the time of inspection, the service was re-working the admission, discharge and transfer procedures used at the service.” from the report
- 01Is the female-only lounge available exclusively to female patients whenever they need it?
- 02Which policies still contain blank spaces or need updating, and when will this work be completed?
- 03What training do staff receive in rehabilitation and recovery-focused practice?
- 04Have the admission, discharge and transfer procedures now been completed and put into use?
- 05Have the conditions preventing new admissions from the earlier inspection been removed?
This was an unannounced focused inspection that checked improvements linked to the earlier warning notices and covered all five key questions; the report says removal of registration conditions was a separate process. This explanation was written from the published report of 19 October 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, January 2023
Ashwood Court Supportive Pathways was inspected but not rated; inspectors found major improvements, but policies and physical intervention training still needed work.
This was a focused inspection on parts of Safe and Well-led. Inspectors visited the home, spoke with three patients and staff, reviewed four care records, checked all patients’ risk assessments and medicines, and examined policies and other records.
The home had improved since the previous inspection in May 2022. All patients had risk assessments and care plans. Medicines were correct and incidents were being reported and reviewed. New audits and electronic records gave managers better oversight.
There were still important gaps. Some policies were not detailed enough, mandatory training was incomplete in first aid and manual handling, and physical intervention training did not cover floor restraint or clearly show that it met patients’ needs.
The home was not given a new rating. The previous overall rating was Inadequate, with Safe and Well-led rated Inadequate and Effective, Caring and Responsive rated Requires improvement. The report says the warning notices checked during this inspection had been complied with, but the previous ratings remained in place.
Risk records
All patients had clear risk assessments and risk management plans. Staff knew about patients’ risks and how to respond.
“All patients had a comprehensive risk assessment in place which clearly identified all risks and had a clear risk management plan to mitigate any risks.” from the report
Care records
Care records had become more complete, current and personalised. Audits and extra staff training were being used to check their quality.
“Care plans were detailed, written in the first person and personalised to reflect the patient’s preferences and opinions.” from the report
Medicines
Inspectors found medicines and records in order. The home had introduced regular medicines checks and audits.
“We checked the medicines stock during the site visit and this matched the medicines recorded.” from the report
Incident response
Staff reported incidents properly, investigated them and made some changes as a result. Restraint use was low and staff tried de-escalation first.
“The service had not been required to use any physical interventions in the last three months.” from the report
Patient involvement
Patients said care was decided with them and that they could raise issues through meetings or forms.
“All patients described feeling safe and that their care was decided with them collaboratively” from the report
Policies lacked detail
needs fixingSeveral policies did not give staff enough clear guidance. This included safeguarding, child visitors, missing people, searches and physical restraint.
“Policies and procedures were not comprehensive and detailed to ensure staff had a clear understanding of their actions and responsibilities.” from the report
Incomplete training
needs fixingOverall mandatory training was 92% complete, but first aid training was 44% and manual handling training was 65% at the inspection.
“First aid training 44%. Three members of staff had been booked onto the first aid training in the weeks following the inspection.” from the report
Physical intervention training
seriousStaff had basic physical intervention training but were not trained in floor restraint. Inspectors said the training needs had not been properly risk assessed against the needs of patients.
“The provider had not taken reasonable steps to demonstrate that the physical intervention training needs of the service had been risk assessed” from the report
Admission checks
needs fixingAdmission documents did not clearly show how people likely to need higher levels of physical intervention, or who might be violent or aggressive, would be prevented from being admitted.
“The pre-assessment documents for patients being considered by the service, did not clearly demonstrate that patients at risk of presenting with violent and aggressive behaviour would not be admitted.” from the report
Activities and staffing for leave
minorOne patient said there were not always enough staff to support as much leave as they wanted. Another said some activities were not age appropriate and patients could spend long periods watching television.
“One patient felt there were not always enough staff to facilitate leave as much as they would like and thought that more day trips should be offered.” from the report
- 01Have all the policies identified by inspectors been rewritten, especially the safeguarding, missing person, search, visitor and physical intervention policies?
- 02What physical intervention training do staff now have, including training for an unplanned floor restraint, and how has this been risk assessed?
- 03Are first aid and manual handling training now complete for all staff?
- 04How do you assess new patients to make sure their needs can be safely managed and that the admission criteria are followed?
- 05What activities and support for leave are now available, and how do you make sure they are suitable for patients’ ages and interests?
This was a focused inspection of elements of Safe and Well-led only; Effective, Caring and Responsive were not inspected and the previous ratings remained in place. This explanation was written from the published report of 13 January 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.
Every inspection of Ashwood Court Supportive Pathways
4 rated inspections over 7 years: the service has held its Good rating throughout.
- October 2023Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Ashwood Court Supportive Pathways →
- January 2023Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
Read what inspectors found at Ashwood Court Supportive Pathways →
- July 2022Inadequatedown from GoodSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- September 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 23 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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