CQC report explained · a residential care home
What the CQC found at 3 Ashley Avenue
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Staff understood people's individual risks and there were enough staff to meet people's support needs. Medicines, recruitment checks, fire safety and infection control were managed appropriately.
- Effective?
- Good
- Staff received induction, specialist training and regular supervision. People were supported with food, fluids, healthcare appointments and complex health needs such as epilepsy.
- Caring?
- Good
- Staff treated people with dignity, kindness and respect. They used different communication methods to understand people's choices and supported family relationships.
- Responsive?
- Good
- Care plans reflected people's routines, preferences, communication and interests. Staff supported individual goals, activities and transitions to supported living.
- Well-led?
- Good
- Managers were visible and approachable, and staff felt supported. Audits and action plans were used to monitor quality and make improvements.
What inspectors found, May 2019
Blythson Limited - 3 Ashley Avenue is rated Good; inspectors found caring, safe support and clear improvements since the previous inspection.
This was a planned, announced inspection by one inspector on 19 February 2019. The inspector reviewed care records, medicine records, staff recruitment and training records, accident records and the systems used to manage the home.
The home supported two people at the time, with a third person preparing to move in. Inspectors observed people because they could not give verbal feedback. They also spoke with staff, managers, a relative and health and social care professionals.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough trained staff, safe medicines systems, personalised care and kind support. The home had improved its records and monitoring after being rated Requires improvement at the previous inspection.
Kind relationships
Inspectors saw staff being attentive and compassionate. People appeared comfortable and relaxed with staff.
“We observed that staff were kind, attentive, interactive and compassionate in their support of people.” from the report
Personalised care
Care plans covered people's needs, wishes, communication, routines and interests. Staff adapted support to people's moods and preferences.
“Care plans were person centred and addressed people's individual needs, wishes and preferences.” from the report
Safe staffing
The provider used recruitment checks and had enough staff with the skills and knowledge to support people safely.
“There was enough staff on duty to provide people with all their support needs.” from the report
Learning and improvement
The home acted on the previous inspection findings. Its records, audits and action plans were more effective at identifying and addressing shortfalls.
“Records showed that systems to monitor the quality of the services provided to people were in place and carried out thoroughly with action plans for identified shortfalls to be met.” from the report
Inspectors raised no specific concerns in this report.
- 01How will you make sure my relative's communication methods and choices are understood by every member of staff?
- 02What training do staff have for my relative's specific health needs, and how are changes in those needs recorded and shared?
- 03How will you measure and review my relative's progress towards their personal goals?
- 04How are relatives kept informed about care, health changes and progress?
- 05How do your audits identify problems, and how do you check that agreed improvements have been completed?
This was a planned inspection of the whole care home, including the premises and care, and all five CQC questions were assessed; people could not give verbal feedback, so inspectors observed them and gathered views from others. This explanation was written from the published report of 9 May 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.
What inspectors found, March 2018
Blythson Limited - 3 Ashley Avenue was rated Requires Improvement in all five areas; inspectors found kind, skilled support but important weaknesses in records, consent and management.
Inspectors visited on 4 January 2018. The visit was announced and included time with all three residents, discussions with staff and professionals, and checks of care plans, risk assessments, medicines, recruitment, training and audits.
The home had enough staff, safe recruitment, safe medicines practices and staff who knew residents well. People were treated with kindness, supported with healthcare, encouraged to take part in activities and helped to make choices.
However, care plans and risk assessments were repetitive and did not always give clear guidance. Records did not always show learning from incidents or progress towards goals. Capacity assessments and best-interest decisions were not always recorded correctly.
The home was rated Requires Improvement overall and in Safe, Effective, Caring, Responsive and Well-led. This was a decline from the previous Good rating in October 2015. Inspectors found five breaches of regulations and required the provider to report what it would do.
Safe medicines
Staff who gave medicines were trained and assessed as competent. Records were completed accurately and medicines were stored safely.
“People's medicines were managed by staff who were trained and had been assessed as competent to do so.” from the report
Kind relationships
Staff knew people well and were observed treating them with kindness, patience, dignity and respect.
“People were treated with kindness and compassion by staff who knew them well.” from the report
Activities and community life
People took part in activities they enjoyed, including community projects, bowling and playing pool. Staff respected people's choices when they did not want to join in.
“People took part in a range of activities, which they told us they enjoyed, including local community projects.” from the report
Health support
Staff understood people's health needs and worked with health professionals. They supported people to attend appointments and helped reduce distress around treatment.
“The staff are very good at supporting people with their health needs. They advocate for people and fight for them to get the right treatment.” from the report
Incomplete incident records
seriousActions taken after accidents and incidents were not always recorded or reviewed. This was part of a breach of Regulation 17.
“The provider and registered manager had failed to maintain accurate and complete records in relation to incidents and accidents.” from the report
Consent and best-interest decisions
seriousCare plans did not always contain decision-specific capacity assessments or records showing how best-interest decisions had been made. This breached Regulation 11.
“The provider had failed to act in accordance with the MCA 2005.” from the report
Unclear care plans and goals
seriousCare plans were lengthy and repetitive, but did not always explain how people liked to be supported. Goals did not show people's involvement, the steps needed or progress made. This breached Regulation 9.
“There was no evidence of people's involvement in identifying their own goals and all goals record related only to daily living skills.” from the report
Weak quality checks
seriousThe home's audits had not identified the shortfalls found by inspectors. Managers had not consistently recorded learning or challenged poor recording by staff. This breached Regulation 17.
“Audits had been completed by they had not identified the shortfalls found at this inspection.” from the report
Late notifications and missing rating
seriousNotifications about Deprivation of Liberty Safeguards authorisations were not sent to CQC without delay. The rating was also not displayed on the website or in the home when inspectors arrived. These were breaches of Regulations 18 and 20A.
“The registered manager had not submitted notifications in line with required time scales.” from the report
Negative recording
needs fixingSome incident and behaviour records described people negatively. The manager agreed this was inappropriate and said it would be addressed.
“We found a number of incident forms and behaviour observation forms in which staff recorded information about people in a negative way.” from the report
- 01How have you simplified care plans and risk assessments so staff can clearly follow each person's preferences and support needs?
- 02How do you record decision-specific capacity assessments and best-interest decisions?
- 03How do you involve each person in choosing goals and record the steps and progress towards them?
- 04How do you check that incident records are respectful, complete and followed by effective action?
- 05What changes have you made to your audits and notification process since this inspection?
This was an announced inspection of the whole service, covering all five CQC questions and the care, accommodation and records reviewed during the visit. This explanation was written from the published report of 4 March 2018 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 3 Ashley Avenue
3 rated inspections over 3 years: the service has held its Good rating throughout.
- May 2019Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 18 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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