CQC report explained · a residential care home
What the CQC found at Ballards Ash
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risk information, medicines management, incident recording and infection control had improved. However, some incidents were not used effectively to prevent them happening again, and inspectors received two whistle-blowing concerns that were being investigated.
- Effective?
- Good
- This question was not assessed during this focused inspection. Its previous rating was carried forward.
- Caring?
- Good
- This question was not assessed during this focused inspection. Its previous rating was carried forward.
- Responsive?
- Good
- This question was not assessed during this focused inspection. Its previous rating was carried forward.
- Well-led?
- Requires improvement
- Quality monitoring had improved and an action plan was in place. However, staff gave divided views about management support, morale and whether concerns were dealt with properly.
What inspectors found, April 2021
Requires Improvement; inspectors found important safety improvements, but concerns remained about staff support, skill mix and management culture.
This was a focused inspection on 11 February 2021. Inspectors checked Safe and Well-led, reviewed records, observed people and staff, spoke with staff and managers, and contacted health and social care professionals. The inspection took place during the pandemic.
The home had improved its incident records, risk information, medicines management and infection control. Inspectors saw calm, organised support during lunch, and staff generally followed care plans. However, feedback about staff support and management was mixed. High staff turnover and limited experience affected the skill mix on some shifts.
The home was rated Requires Improvement overall. Safe and Well-led were both rated Requires Improvement. The report says the home was no longer breaching regulations from the previous inspection, but further improvements were needed. This was the second consecutive Requires Improvement rating.
Better risk information
Care plans contained detailed information about risks such as epilepsy, positive behaviour management and choking. Inspectors also found clearer recording and review of behavioural incidents.
“Risk management information was available within the appropriate section of people's care plans.” from the report
Medicines were managed safely
Inspectors observed safe medicines administration. Records were complete, medicines were securely stored and staff had been trained and assessed.
“Medicines administration records had been fully completed.” from the report
Improved infection control
The home had improved its infection control since the previous inspection. Inspectors saw correct protective equipment, clean areas, extra cleaning and testing arrangements.
“At this inspection there had been significant improvements.” from the report
Calmer support
During lunch, staff worked together in a calm and supportive way. People were supported according to their care plans, including with meals and communication.
“At this inspection we saw staff worked in co-ordinated ways to ensure people were engaged in a calm and supportive manner.” from the report
Improved oversight
The home had quality checks, an action plan and regular staff meetings. Extra management and behavioural support had also been added since the previous inspection.
“There was a clear action plan with timeframes for completion and who would be overseeing which areas of improvement.” from the report
Staff morale and confidence
needs fixingStaff feedback was divided. Some staff did not feel their concerns would be listened to or handled quickly, and inspectors said the staff culture still needed improvement.
“There was mixed feedback from staff regarding the culture, with some feeling it was now more positive but others who felt the culture needed further improvement.” from the report
Staff turnover and experience
needs fixingStaff raised concerns about high turnover and inexperienced staff. Inspectors also heard that some staff needed more information about people's needs before supporting them alone.
“It's lack of experienced staff as so many staff have and are leaving.” from the report
Concerns raised about people's care
seriousTwo whistle-blowing concerns were raised during the inspection. They included concerns about managing one person's needs and whether a staff risk assessment had been properly implemented.
“During this inspection we received two whistle-blowing concerns.” from the report
Some incidents were not fully used for learning
needs fixingAlthough incident recording had improved, inspectors found that some less serious concerns were not always discussed effectively to reduce the chance of repetition.
“However, some staff felt this needed to be done more effectively, especially for less serious concerns.” from the report
One missed notification
needs fixingOne notification about unsafe practice had not been sent to CQC as required. The home said this was an oversight and planned to send it without further delay.
“One notification had not been submitted to CQC in line with the provider's registration requirements.” from the report
- 01How are you reducing staff turnover and making sure each shift has enough experienced staff who know people's individual needs?
- 02How do you make sure staff concerns are listened to, investigated promptly and acted on?
- 03What changes have you made so that every incident, including less serious incidents, is reviewed and used to improve people's safety?
- 04What happened after the two whistle-blowing concerns raised during the inspection, and what actions followed?
- 05How are you checking that new staff have enough information and support before working with someone alone?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 2 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.
What inspectors found, September 2020
Rated Requires Improvement overall, with Safe rated Inadequate; inspectors found risks were not controlled and management systems were weak.
This was an unannounced, focused inspection on 8 July 2020. Inspectors looked only at Safe and Well-led. They observed people, spoke with relatives, staff and professionals, and reviewed care, medicine, staffing and management records.
Inspectors found that people could be at risk of avoidable harm. Staff did not always follow care plans or use consistent approaches to behaviour. There were concerns about staffing, training, infection control, personal care records and medicines records. The home had not always learned from incidents or acted on repeated problems.
The home was rated Inadequate for Safe and Requires Improvement for Well-led. The overall rating fell from Good at the previous inspection in December 2017 to Requires Improvement. The other three question ratings were not inspected at this visit and were carried forward from the previous comprehensive inspection.
Some families felt reassured
Most relatives spoken with said they were happy with the home and praised the care. However, this was not the experience of every relative.
“Most family members we spoke with felt their relative was safe.” from the report
Feedback opportunities
People had opportunities to attend meetings and give feedback through surveys. Inspectors noted that not everyone could understand or use this process fully.
“People in the home had the opportunity to attend service user meetings and provide feedback through a survey.” from the report
Action after inspection
After the inspection, the provider shared an action plan and said it would increase management support, review staff responses and improve infection control arrangements.
“The provider has shared details of their action plan to address the concerns raised.” from the report
Risk of harm
seriousRisk assessments existed, but staff did not always read or follow them. Responses to aggression and distress varied, and inspectors found that risks were not adequately reduced.
“people were not safe and were at risk of avoidable harm.” from the report
Inconsistent behaviour support
seriousStaff used different approaches to people’s behaviour and did not always follow care plans. Inspectors saw situations where this increased anxiety and the risk of aggression.
“The management of these types of behaviours was not always safe or effective.” from the report
Infection control
seriousUse of protective equipment was inconsistent. Some areas were unclean, waste arrangements were unsuitable and cleaning records had gaps.
“good infection prevention control systems were not always maintained.” from the report
Medicines records
seriousThere had been medicine errors, missing signatures and incorrect stock checks. The repeated recording problems showed that previous actions had not solved the issue.
“the continued errors demonstrated that the action taken had not been effective in reducing these errors” from the report
Weak management oversight
seriousQuality checks identified problems, but similar issues continued. Inspectors also found evidence that some records had been falsified or completed after the event.
“some documentary evidence was being falsified and backdated.” from the report
Staffing and support
needs fixingStaff consistently reported that staffing was not enough for people’s needs. Feedback about training, management support and staff wellbeing was mixed, with several staff feeling worn down.
“Staff consistently told us they felt there was not enough staff to meet people's needs effectively.” from the report
- 01What action has been taken to make behaviour support consistent with each person’s care plan?
- 02How do you now check that staff have enough training and time to support people safely?
- 03What changes have been made to medicines checks, signatures and error follow-up?
- 04How do you make sure cleaning, protective equipment and waste disposal are completed correctly every day?
- 05How do you check that records are completed accurately at the time care is given?
This was a focused inspection of Safe and Well-led only; the Effective, Caring and Responsive ratings were not inspected and previous ratings were used in calculating the overall rating. This explanation was written from the published report of 2 September 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 Ballards Ash
4 rated inspections over 4 years: the service has held its Requires improvement rating throughout.
- April 2021Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2020Requires improvementdown from GoodSafe: InadequateWell-led: Requires improvement
- December 2017Goodup from Requires improvementSafe: GoodWell-led: Good
- December 2016Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Good
- January 2014
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 8 December 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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