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Axbridge Court Nursing Home Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 19 July 2019

About the service

Axbridge Court Nursing Home is residential care home providing personal and nursing care to 31 people aged 65 and over at the time of the inspection. The service can support up to 36 people.

People’s experience of using this service and what we found

There was not a registered manager in post. A registered manager and provider are legally responsible for how the service is run and for the quality and safety of the care provided. A new manager had been identified and was due to take up the post mid-June 2019.

People were not always protected from potential harm. Some contractor checks on the premises had not been carried out. This shortfall had been identified by the operations manager and the visits had been booked in June 2019. Checks that certain items of electrical equipment were safe to use had not always been carried out or reviewed.

People at risk of developing pressure ulcers were at risk of potential harm as pressure relieving mattress settings were not being checked regularly. However, there were additional systems in place which were being used effectively to prevent pressure ulcers developing.

Fluid input and output charts were not being monitored by senior staff to ensure people identified at risk of dehydration were receiving enough fluids. However, staff were very proactive in ensuring people had sufficient fluids throughout the day/night.

Staff understood their roles and responsibilities, however they lacked strong leadership. People, relatives and staff told us they had not been kept fully informed of changes that had occurred in the home. There were plans in place to involve people, relatives and staff more.

There were systems in place to identify shortfalls and drive improvement. However, those systems in use prior to a new audit carried out by the operations manager had failed to identify some shortfalls. For example, the failure of senior staff to monitor pressure mattress settings and fluid input and output charts.

New systems in place had identified some shortfalls and an action plan was in place. However, these systems need to provide assurance that they can be used consistently, and improvement sustained.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff demonstrated a good understanding of people’s needs and received training relevant to their role and the needs of people living in the home. People enjoyed a healthy balanced and nutritious diet based on their preferences and health needs.

People received care from staff who were kind and caring. Staff respected people’s privacy and dignity. Staff encouraged people to be involved in their care planning and reviews. People were supported to express an opinion about the care provided.

People received responsive care and support which was personalised to their individual needs and wishes and promoted independence. There was clear guidance for staff on how to support people in line with their personal wishes, likes and dislikes.

Rating at last inspection.

The last rating for this service was Good (published 9 December 2016). At this inspection the service is rated Requires Improvement.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

For more details, please see the full report which is on the CQC website at

Inspection areas


Requires improvement

Updated 19 July 2019

The service was not always safe.

Details are in our safe findings below.



Updated 19 July 2019

The service was effective.

Details are in our effective findings below.



Updated 19 July 2019

The service was caring.

Details are in our caring findings below.



Updated 19 July 2019

The service was responsive.

Details are in our responsive findings below.


Requires improvement

Updated 19 July 2019

The service was not always well-led.

Details are in our well-Led findings below.