CQC report explained · a nursing home
What the CQC found at Astley Hall Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, November 2022
Rated Good overall; inspectors found safe care, but the home was Requires Improvement for leadership and record keeping.
This was an unannounced focused inspection on 20 and 21 September 2022. Inspectors looked only at Safe and Well-led because concerns had been raised about medicines and staffing. They spoke with people, relatives and staff, and checked care, medicines, staffing, cleaning and management records.
Inspectors found people were safe, medicines were managed safely and there were enough staff during the inspection. Staff were recruited safely, knew how to recognise abuse and supported people under the Mental Capacity Act.
The main weakness was management oversight. Records did not always show that people had been repositioned or checked hourly when they could not use their call bell. Cleaning records were also incomplete. The overall rating improved from Requires Improvement to Good, but Well-led remained Requires Improvement.
Safe medicines
Inspectors found that medicines were received, stored, given and disposed of safely. Staff were trained and assessed before giving medicines.
“Medicines were safely managed. Safe protocols for the receipt, storage, administration and disposal of medicines were followed.” from the report
Protection from harm
People told inspectors they felt safe. Staff knew how to recognise abuse and what action to take.
“People were cared for safely and were protected from the risk of harm.” from the report
Risk planning
People had care plans for risks such as poor nutrition, dehydration and pressure sores. Staff monitored these risks and took action when needed.
“Risks to people's health and well-being had been identified and plans were in place to mitigate the risk.” from the report
Supportive staff culture
Staff spoke positively about the management and said they felt supported in their work.
“There was a positive culture within the home and staff told us they felt supported in their roles.” from the report
Incomplete care records
needs fixingStaff did not always record repositioning at the required times. This made it harder to show that pressure sore prevention care had been provided.
“People who were at risk of pressure sores required support from staff to reposition at regular timed intervals to reduce the risk of developing pressure sores, however, staff did not always record repositioning had taken place at the required times.” from the report
Hourly checks were not recorded
needs fixingThere was no effective system to check that hourly safety checks had been recorded for people who could not use their call bell. The manager introduced a new recording system during the inspection.
“People were at risk of not receiving timely care, when required, as there was no system to check whether staff had recorded hourly safety checks for people who could not use their call bell for assistance.” from the report
Cleaning records
needs fixingCleaning tasks were not always recorded, and staff shortages meant some tasks were not completed. The home was recruiting more domestic staff.
“We identified gaps in recording of cleaning tasks. This meant that we could not be assured the provider was promoting safety through the layout and hygiene practices of the premises.” from the report
Leadership systems not embedded
needs fixingQuality checks had improved but were not yet consistent and reliable enough to identify and prevent all record-keeping shortfalls.
“Quality assurance systems need to be sustained and embedded to ensure they are consistent and reliable in identifying the shortfalls we found in record keeping.” from the report
- 01How do you now make sure repositioning is completed at the required times and recorded straight away?
- 02How do you check that hourly safety checks are completed for people who cannot use their call bell?
- 03Have all cleaning tasks been completed and recorded consistently since the inspection?
- 04What evidence can you show that your quality checks are now consistent and identify missing care records?
- 05How do you make sure there are enough permanent and agency staff on each shift?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were not assessed during this visit and the overall rating used previous ratings for those areas. This explanation was written from the published report of 1 November 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, April 2021
Astley Hall is Rated Requires Improvement; inspectors found kind, responsive care but gaps in medicines, safety records and management oversight created risks.
This was the home's first inspection after registration. It was unannounced and took place on 16 February 2021. The inspection was prompted by concerns about infection control and record keeping. The inspector spoke with people, relatives and staff, and checked care records, medicines, staff files and management records.
The home was rated Good for Effective, Caring and Responsive. People were supported by trained staff who knew them well. Inspectors found person-centred care, involvement in care planning, activities and support to keep in contact with relatives. People and relatives described staff as kind and respectful.
The home was rated Requires Improvement for Safe and Well-led, giving an overall rating of Requires Improvement. Inspectors found missing or incomplete records for repositioning, skin checks, weights, injuries and medicines. The management systems had not identified these problems. The manager sent an action plan, and the CQC said it would continue to monitor the home.
Kind and respectful staff
People and relatives described staff as kind, caring and respectful. Staff knew people's needs and protected their privacy.
“A relative told us, "The staff are always kind, caring and responsive to [person's] needs.” from the report
Trained staff
Staff completed induction, training and shadow shifts. Inspectors found they understood their roles and knew how to support people.
“All staff completed an induction which included training and shadow shifts, to ensure they had the knowledge and skills to carry out their roles and responsibilities.” from the report
Personalised support
Care plans included people's likes, dislikes, communication needs, culture, religion and lifestyle choices. People and relatives were involved in planning care.
“Care plans contained personalised information within them including peoples likes and dislikes, emotional support needs and how they preferred to be communicated with.” from the report
Activities and family contact
The home arranged activities and supported people to stay in contact with relatives through window visits, video calls and telephone calls.
“People and their relatives were supported to stay in contact with each other during the COVID-19 pandemic.” from the report
Incomplete safety records
seriousRecords did not always show that repositioning, skin checks, pressure equipment checks, weights and other required checks had been completed. Injuries were not always recorded or investigated.
“Records management required improvement. We found gaps in the recording of care tasks including repositioning checks, skin integrity checks and weight monitoring for people who required these tasks to be completed for health concerns.” from the report
Medicine recording and administration
seriousNot all prescribed medicines had a medication administration record, and some administration records had gaps. Reasons for giving medicines when needed were not always recorded, creating a risk of incorrect medicine or dosage.
“Not all medicines that were administered had signed medicine administration record [MAR] in place.” from the report
Weak management oversight
seriousAudits and monitoring systems did not identify the problems found during the inspection. The home was redesigning its systems and had sent an action plan.
“Systems and processes were not robust enough to identify the issues we found during the inspection.” from the report
Some infection-control records
needs fixingThe environment appeared clean, but there were gaps in cleaning-schedule records. The provider was still putting some signage in place.
“We found gaps in the records of cleaning schedules. However, the environment appeared clean.” from the report
- 01What has been done to ensure every prescribed medicine has a signed medication administration record, and that reasons for 'as required' medicines are recorded?
- 02How do you now check and record repositioning, skin integrity, pressure equipment, weights and other care tasks?
- 03How are bruises and other injuries recorded, investigated and followed up?
- 04What new audits are in place to identify missing care records, medicine errors and cleaning records before they put people at risk?
- 05Has the action plan sent after the inspection been completed, including dementia-friendly signage and end-of-life training for staff?
This was an unannounced first inspection focused on concerns about infection control and record keeping, and it assessed all five CQC questions for the newly registered home. This explanation was written from the published report of 9 April 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 Astley Hall Care Home
2 rated inspections over 2 years: the service has improved, from Requires improvement to Good.
- November 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2021Requires improvementSafe: Requires improvementWell-led: Requires improvement
- September 2020
Registered with the Care Quality Commission on 16 September 2020.
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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