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Ashbourne House - Bristol Good

Inspection Summary

Overall summary & rating


Updated 10 November 2017

This inspection took place on 28 September 2017 and was unannounced. Ashbourne House is registered to provide accommodation and personal care for up to 17 people. At the time of our visit there were 15 people living at the service.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At our last inspection in June 2016 we rated the service overall as Requires Improvement. At that inspection we found a breach of Regulations 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because there were not appropriate procedures for the administration and recording of PRN (as required) medicines. We also found that although improvements had been made since the inspection of August 2015 and previous breaches had been met we had to be satisfied that these would be sustained over time.

Following the inspection we told the provider to send us an action plan detailing how they would ensure they met the requirements of that regulation. At this inspection we saw the provider had taken action as identified in their action plan and improvements had been made. In addition they had sustained previous good practice. As a result of this inspection the service has an overall rating of Good.

Why the service is rated Good.

The registered manager and staff followed procedures which reduced the risk of people being harmed. Staff understood what constituted abuse and what action they should take if they suspected this had occurred. Staff had considered actual and potential risks to people, plans were in place about how to manage, monitor and review these.

People were supported by the service’s recruitment policy and practices to help ensure that staff were suitable. The registered manager and staff were able to demonstrate there were sufficient numbers of staff with a combined skill mix on each shift.

Staff had the knowledge and skills they needed to carry out their roles effectively. They were supported by the provider and the registered manager at all times. Staff had completed nationally recognised qualifications in health and social care and others were in the process of completing this.

People received a service that was based on their personal needs and wishes. Changes in people’s needs were quickly identified and their care amended to meet their changing needs. The service was flexible and responded very positively to people’s requests. Staff demonstrated a genuine passion and commitment for the roles they performed and their individual responsibilities. It was important to them those living at the service felt ‘valued and happy’.

People were helped to exercise choices and control over their lives wherever possible. Where people lacked capacity to make decisions a process of best interest decision making had been followed that was consistent with the principles of the Mental Capacity Act 2005 (MCA). The Deprivation of Liberty Safeguards (DoLS) were understood by staff and appropriately implemented to ensure that people who could not make decisions for themselves were protected.

People benefitted from a service that was well led. People who used the service felt able to make requests and express their opinions and views. Staff embraced new initiatives with the support of the registered manager and deputy. They continued to look at the needs of people who used the service and ways to improve these so that people felt able to make positive changes.

The provider and registered manager had implemented a programme of ‘planned growth’ that was being well managed and they were committed to continuous improvement. An increase in the provider’s oversight meant that a significant number

Inspection areas



Updated 10 November 2017

The service had improved to Good.

Appropriate action was taken to ensure there were enough care staff to support people.

Staff had received training in safeguarding so they would recognise abuse and know what to do if they had any concerns.

People received care from staff who took steps to protect them from unnecessary harm. Risks had been appropriately assessed and staff had been provided with clear guidance on the management of identified risks.

People were protected through the homes recruitment procedures. These procedures helped ensure staff were suitable to work with vulnerable people.

People were protected against the risks associated with unsafe use and management of medicines.

Appropriate health and safety checks were undertaken to reduce risks to people.



Updated 10 November 2017

The service had improved to Good.

People were cared for by staff who had received sufficient training to meet their individual needs.

People were cared for by staff who received regular and effective support and supervision.

Staff promoted and respected people�s choices and decisions. The registered manager and senior staff had a good understanding of the Mental Capacity Act 2005 (MCA).

Where necessary people were provided with a healthy diet which promoted their health and well-being and took into account their nutritional requirements and personal preferences.



Updated 10 November 2017

The service remained caring.



Updated 10 November 2017

The service had improved to Good.

Staff identified how people wished to be supported so that it was meaningful and personalised.

Independence was encouraged and supported wherever possible.

People were encouraged to pursue personal interests and hobbies and to join in activities.

People were listened to and staff supported them if they had any concerns or were unhappy.



Updated 10 November 2017

The service had improved to Good.

The vision, values and culture of the service was understood by people and staff.

Effective quality monitoring systems had been implemented. Audits were being completed to regularly assess the quality and safety of the service provided.

People, their relatives and staff were encouraged to share their opinions about the quality of the service, to ensure planned improvements focused on people's experiences.

The manager and other senior staff were well liked and respected.