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Ashwood House - Norwich Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 11 September 2021

About the service

Ashwood House - Norwich is a residential care home providing personal care to up to seven younger adults with a learning disability, sensory impairment, physical disability or mental health condition. There were seven people living there at the time of this inspection. The service accommodates five people in the main house with a shared communal lounge and kitchen. Accommodation for a further two people is provided in two self-contained flats.

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

The person-centred and quality care that people received had been failed by the provider’s lack of governance systems. This meant there was no effective and accurate oversight, assessment and review system being used. Two concurrent care planning systems were in place running the risk that neither were fully reliable or effective. Important information was either not being captured at provider level or potentially being missed by staff.

Whilst some audits were being completed to assess and monitor the service, we had doubts about their integrity and effectiveness. This was because we saw some records had been pre-populated and others which had been amended. Furthermore, the audits that were in place had either not identified the concerns we found at this inspection or failed to rectify them.

Improvements in the care and support people received was noticeable at this inspection and people’s human rights were being better supported. Although not all risks had been identified and recorded as required, they were mitigated to some degree in practice however improvements are needed in this area.

People received care from staff who were motivated, skilled and knowledgeable, and understood their needs. Staff had received regular support and training and had been safely recruited. Medicines were managed safely. Staff understood their responsibilities around protecting people from the risk of abuse and improper treatment. They knew people’s needs well.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right Support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

Based on our review of the Safe and Well-led key questions, the service was able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture. The service had been registered prior to the guidance however it met the key characteristics due to its small size, position in the community and homely environment. People received person-centred care that concentrated on their strengths, and a proactive and integrated approach had been adopted.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 05 January 2021) and there were multiple breaches of regulations. We imposed conditions on the provider’s registration which meant they had to submit monthly reports explaining the improvements they were making.

At this inspection, whilst we found some improvements, further development is required, and the provider remains in breach of regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

We received concerns about the provider’s governance systems and oversight of the service. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of c

Inspection areas


Requires improvement

Updated 11 September 2021

The service was not always safe.

Details are in our safe findings below.



Updated 11 September 2021



Updated 11 September 2021



Updated 11 September 2021


Requires improvement

Updated 11 September 2021

The service was not always well-led.

Details are in our well-Led findings below.