CQC report explained · a nursing home
What the CQC found at Pathfinder Ashness House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, April 2023
Pathfinder Ashness House was rated Good overall, but inspectors found Effective Requires Improvement and continuing weaknesses in rights information and care planning.
This was an unannounced, comprehensive inspection on 8 and 9 December 2022. Inspectors visited the home, spoke with five patients and 14 staff, reviewed six care records, checked medicines and examined management documents.
The home had improved since a focused inspection in September 2022, which found serious concerns about restraint records and physical health checks after rapid tranquilisation. Inspectors found these issues had been addressed. They rated Safe, Caring, Responsive and Well-led as Good.
The Effective rating was Requires Improvement. Staff did not always explain detained patients’ rights in a way they could understand. Care plans sometimes used generic statements, goals were not always clear and achievable, and patients were not always supported to live healthier lives. The overall Good rating means inspectors found the service generally provided good care, but improvements were still needed.
Improved safety
The home had acted on serious concerns found at the previous inspection. Restraint records and physical health checks after rapid tranquilisation had improved.
“The service had addressed the concerns raised at the last inspection in September 2022.” from the report
Safe medicines management
Medicines were prescribed, administered, stored and reviewed safely. External pharmacy checks were carried out weekly.
“Staff managed medicines safely and regularly reviewed the effects of medications on each patient’s mental and physical health.” from the report
Kind and respectful care
Patients told inspectors that staff treated them well, listened to them and respected them. Inspectors also observed compassionate and calm support.
“Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity.” from the report
Suitable staffing and expertise
Despite nursing vacancies, inspectors found enough staff on each shift. The team included, or could access, the specialists needed for rehabilitation.
“The service had enough nursing and medical staff, who knew the patients and received essential training to keep people safe from avoidable harm.” from the report
Clean and suitable environment
The ward was clean, well maintained and equipped for patients’ treatment, privacy and dignity.
“The ward was safe, clean, well equipped, well furnished, well maintained and fit for purpose.” from the report
Mental Health Act rights
seriousDetained patients were not always given information about their rights in a way they could understand. Records did not always show that staff had repeated the information or used communication aids when needed.
“Patients detained under the Mental Health Act did not always have their rights explained to them in a way they could understand.” from the report
Restricted items and practices
needs fixingThe list of prohibited items was not displayed for patients. Some staff did not know what restrictive practices were being used on the ward.
“Staff had not displayed a sign to inform patients of what items were prohibited.” from the report
Personalised care plans
needs fixingSome care plans relied on generic statements. Patient goals were not always specific, measurable or achievable, and one risk management plan did not clearly set out the required actions.
“Patient goals, whilst present, were not always specific, measurable or achievable.” from the report
Healthy-living support
minorPatients could smoke in the garden and nicotine replacement therapy was not offered at the home. Patients had to be referred to their GP for help to stop smoking.
“The hospital site was not smoke-free as patients could still smoke in the garden area.” from the report
Discharge information
needs fixingSome patients did not know what their discharge plan was, even though staff were planning and managing discharges.
“Three patients did not know what their discharge plan was.” from the report
- 01How will you make sure detained patients understand their Mental Health Act rights, including people who have communication difficulties?
- 02How have you improved care plans so that goals and staff actions are specific, measurable and achievable?
- 03How do you now make sure every patient understands their discharge plan?
- 04What restricted items and restrictive practices are currently used, and how are patients told about them?
- 05What support is now available for patients who want to stop smoking or improve their physical health?
This was an unannounced, comprehensive inspection of the long-stay and rehabilitation mental health ward, carried out to check improvements after a focused inspection in September 2022 and to give the service its first rating. This explanation was written from the published report of 6 April 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. The report was longer than we could read in one go; the later sections may not be reflected.
What inspectors found, December 2022
Pathfinder Ashness House was inspected but not rated; inspectors found serious safety and governance concerns and issued a warning notice.
This was an out-of-hours, focused inspection on 18 and 21 September 2022. Inspectors looked only at Safe and Well-led. They visited the home, spoke with patients, relatives and staff, and reviewed care records, medicines and management documents.
Inspectors found serious problems with recording and responding to risks. Not all physical restraints were reported or recorded in enough detail. Physical health checks after rapid tranquilisation were sometimes missing. Staff did not always respond promptly to changes in physical health, and observations were carried out at predictable times.
The home had enough staff on each shift, and the ward was clean, well equipped and well maintained. Patients said staff were kind and respectful. However, inspectors found that senior managers did not have effective systems to monitor risks and improve safety.
The home was not rated because it had not been inspected before and this visit covered only parts of two questions. The CQC issued a section 29 warning notice and told the home to take immediate action.
Staffing levels
Inspectors found enough nursing and support staff on each shift to support patients safely, despite a high number of vacancies.
“The service had enough nursing and support staff to keep patients safe.” from the report
Environment and equipment
The ward was clean, maintained and suitable for use. Emergency equipment and medicines were checked regularly.
“The ward was safe, clean, well equipped, well furnished, well maintained and fit for purpose.” from the report
Kind and respectful care
Patients said staff listened to them, treated them with dignity and respect, and went beyond what they expected to support them.
“Patients said staff treated them well and behaved kindly.” from the report
Restraint records
seriousNot all incidents of physical restraint were reported. Records that were completed did not always include enough detail to show how and for how long restraint was used.
“Staff did not report all incidents of physical restraint.” from the report
Response to physical deterioration
seriousStaff did not always respond promptly to concerning vital sign results or record what action they had taken.
“Staff did not always respond promptly to a deterioration in a patient's physical health or record why no action had been taken in response to elevated results of checks of their vital signs.” from the report
Predictable observations
seriousIntermittent observations were made at regular times rather than at irregular and unpredictable times. Inspectors said patients might be able to plan around these checks.
“Staff did not carry out intermittent level observations on patients at irregular and unpredictable times.” from the report
Weak management systems
seriousSenior managers had not established effective systems to assess and reduce risks. The home could not reliably analyse how often restraint or rapid tranquilisation was used.
“Senior managers had not established effective systems to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients.” from the report
Hard-to-find records
needs fixingPatient information was stored in different places and there was no clear format. This could make it harder for staff, especially agency staff, to find important information quickly.
“Patient notes were not comprehensive, and they were not easy for staff to access.” from the report
- 01What action has the home taken to make sure every physical restraint is reported and recorded in full?
- 02How are physical health checks recorded after rapid tranquilisation, including when a patient refuses them?
- 03How does the home now make sure intermittent observations happen at irregular and unpredictable times?
- 04How are concerning vital signs escalated, and where is the response recorded?
- 05How can staff quickly find a patient's important care and treatment information, especially when agency staff are working?
This was a focused out-of-hours inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected, and no questions were rated. This explanation was written from the published report of 20 December 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.
Every inspection of Pathfinder Ashness House
Each visit the CQC has published, newest first, back to the day the home was registered.
- April 2023Goodcurrent ratingSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- December 2022Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- March 2022
Registered with the Care Quality Commission on 14 March 2022.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
At least 100 live-in carers within about an hour of Harrow
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,330 a week. 81 can care for a couple. 12 years' experience on average.
“She handled the new situation in front of her with such professionalism and I felt I could trust her 100%.”
“I can truly say that Peter always put Dad at the centre of everything and I know that they found a great friendship in difficult times.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.