CQC report explained · a residential care home
What the CQC found at Aylestone Grange
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Staff knew people well and there were enough safely recruited staff. However, written care guidance, mental capacity records and some 'as needed' medicines records were not always complete or clear.
- Effective?
- Good
- This question was not inspected during this focused inspection. Its rating was carried forward from the previous inspection.
- Caring?
- Good
- This question was not inspected during this focused inspection. Its rating was carried forward from the previous inspection.
- Responsive?
- Good
- This question was not inspected during this focused inspection. Its rating was carried forward from the previous inspection.
- Well-led?
- Requires improvement
- Staff spoke positively about the registered manager, but management oversight had not resolved repeated concerns in care planning, mental capacity assessments and 'as needed' medicines guidance.
What inspectors found, June 2023
Rated Requires Improvement; inspectors found staff knew people well, but care records, medicines records and management checks were not reliable enough.
This was an unannounced focused inspection on 11 May 2023. Inspectors looked only at Safe and Well-led because the inspection followed an incident that caused a serious injury. They spoke with four staff and the registered manager, observed care, and checked care, medicines, staff and management records.
Staffing, recruitment, safeguarding, fire safety, infection control and incident handling were generally satisfactory. Staff knew people's needs well and people received their medicines as prescribed. However, written care guidance was not always available or clear, some 'as needed' medicines records were out of date, and mental capacity assessments were not always recorded.
Management checks had not fixed these problems promptly. The provider was found to be in breach of Regulation 17 on good governance. The overall rating changed from Good at the previous inspection to Requires Improvement. Safe and Well-led were both rated Requires Improvement, while the other three questions were not inspected and carried forward from the previous inspection.
Enough staff
Inspectors found enough staff to support people safely. Staff said they were not rushed and had time to spend with people.
“I am never rushed. There are enough of us so we can always spend time with people.” from the report
Staff knew people's needs
Although records were incomplete, the regular staff team had good knowledge of the people they supported. Inspectors said this meant the poor documentation had not caused unsafe care.
“However, staff had received training and had good knowledge of people's needs.” from the report
Safe medicines administration
People received their medicines as prescribed and medicines were stored safely. The main problem was inaccurate or incomplete guidance for medicines given only when needed.
“People received their medicines as prescribed. Staff recorded this administration in line with current recording guidelines.” from the report
Positive staff culture
Staff described a supportive culture and spoke positively about the registered manager. Staff also had regular meetings and supervision.
“All staff described Aylestone Grange as having a good culture where people were supported well.” from the report
Partnership working
The home worked with health and social care professionals. Inspectors found detailed records of at least one person's dental appointment and after-care.
“Records showed that the service had regularly worked with different health professionals.” from the report
Care plans lacked clear guidance
needs fixingCare plans did not always explain clearly how to support people safely. This could create a risk for new or agency staff and visiting professionals.
“Staff did not always have clear written guidance on how to support people safely.” from the report
Mental capacity records incomplete
needs fixingMental capacity assessments were not always recorded, including for decisions about food. This meant inspectors could not be assured that people's ability to make decisions had been properly assessed.
“There were not always mental capacity assessments recorded for people.” from the report
Out-of-date as-needed medicine record
needs fixingOne medicine had stopped being prescribed more than two months earlier but still appeared on the records. Inspectors said this could confuse staff about the person's medicine needs.
“This risks staff becoming confused about the person's medicine needs.” from the report
Management checks did not resolve concerns
seriousAudits and earlier reviews had identified problems, but they had not been fixed promptly. This led to a breach of the good governance regulation.
“Governance systems were not always effective to oversee high quality care.” from the report
Required training not completed
needs fixingCare staff had not received training in supporting people with a learning disability, although this had been a legal requirement since July 2022.
“Care staff had not received training in supporting people with a learning disability.” from the report
- 01Have all care plans now been uploaded correctly, and do they give clear instructions for new or agency staff?
- 02How are mental capacity assessments now completed and checked for every relevant decision?
- 03How do you check that 'as needed' medicines records match current prescriptions?
- 04Has all required learning disability training been completed by care staff?
- 05What actions were included in the action plan sent to CQC, and what evidence can you show that they are complete?
This was an unannounced focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their ratings were carried forward from the previous inspection. This explanation was written from the published report of 8 June 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, November 2020
Aylestone Grange is shown as Good overall, but inspectors found well-led management Requires Improvement and the report also says the overall rating remains Requires Improvement.
This was a focused inspection on 23 September 2020. Inspectors checked Safe and Well-led, spoke with four people and five staff, and reviewed care, medicines, recruitment and management records.
Safe was rated Good. People had risk assessments, enough staff were available, safeguarding procedures were in place, and infection control had improved. One missing COVID-19 risk assessment was added immediately after the inspection.
Well-led remained Requires Improvement. Management systems had improved, but care record audits were not effective and some records had gaps or inconsistencies. The report says the home was no longer breaching regulations found at the previous inspection.
The ratings section lists the overall rating as Good. However, another part of the report says the overall rating remains Requires Improvement. This inconsistency should be clarified with the home or CQC.
Improved safety systems
Medicines, recruitment and other safety processes had improved since the previous inspection. The provider was no longer in breach of the safety regulations identified previously.
“At this inspection we found improvements had been made. The provider was no longer in breach of these regulations.” from the report
Enough staff
Inspectors found there were enough staff on site to keep people safe. The home avoided agency workers during the pandemic by using permanent staff to cover vacant shifts.
“There were enough staff on site to keep people safe.” from the report
Infection control
People and staff took part in regular COVID-19 testing. Cleaning, protective equipment and communal-area arrangements had also been strengthened.
“Staff took infection prevention and control seriously and had made changes to the layout of the communal areas to facilitate social distancing of people living in the service and staff.” from the report
Approachable management
People and staff felt the manager listened and would deal with issues promptly. The manager was open about areas still needing improvement.
“People and staff were confident any issues raised would be dealt with promptly and felt the registered manager was approachable and good at running the service.” from the report
Some medicines checks were incomplete
needs fixingThere were no assessments explaining how people preferred to take their medicines. Checks for one person who self-medicated were not happening as set out in the risk assessment, and records needed strengthening.
“Random spot checks to ensure the person consistently took their medicine were not taking place in line with their risk assessment, and the recording process needed to be strengthened.” from the report
One missing community risk assessment
minorOne person who regularly went out into the community did not have the required COVID-19 risk assessment at the time of inspection. The manager added it immediately afterwards.
“One person who regularly went out did not have a risk assessment, but the registered manager put this in place immediately after the inspection.” from the report
- 01Have all care records been audited, corrected and checked regularly since the inspection?
- 02Have medicines assessments been completed to record how each person prefers to take their medicines?
- 03How are spot checks for people who self-medicate now carried out and recorded?
- 04Can you explain the difference between the report's overall rating of Good and its statement that the overall rating remains Requires Improvement?
- 05How are people and relatives now given opportunities to share their views, including through meetings or surveys?
This was a focused inspection of Safe and Well-led only; ratings for Effective, Caring and Responsive were not assessed during this visit and previous ratings were used in calculating the overall rating. This explanation was written from the published report of 11 November 2020 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 Aylestone Grange
4 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- June 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2020Goodup from Requires improvementSafe: GoodWell-led: Requires improvement
- November 2019Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- January 2017GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- September 2014
Registered with the Care Quality Commission on 23 September 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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