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Inspection Summary

Overall summary & rating


Updated 21 March 2018

We inspected Ash Grove Care Home on 5 and 6 February 2018. The inspection was unannounced. The home has been inspected four times since 2014. At the inspections of December 2014 and July 2015, it was rated as inadequate and a range of breaches in regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were identified. Following these inspections the CQC took enforcement action in accordance with its procedures. An inspection took place in April 2016 where we found improvements had been made and the home was rated as requires improvement. However despite these improvements, we continued to find three breaches in Regulations.

At a further inspection, which took place in May 2017, we found there were still breaches of three regulations. Risks to people were not always safely managed in relation to pressure damage and their health needs. Protocols for people who had been prescribed ‘as required’ medicines were not always in place. There were not always enough staff working to support people safely. Concerns had been identified through the quality assurance system, however, these had not all been addressed. People’s records were not always up to date and did not reflect their current needs. We also identified areas of practice that required improvement to ensure people were consistently supported in a dignified manner, and that people had enough to do during the day. The home was rated Requires Improvement and CQC took enforcement action in accordance with its procedures. The home was also placed in ‘special measures.’

Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

We undertook this unannounced comprehensive inspection to look at all aspects of the service and to check that the provider had made improvements, and confirm that the service now met legal requirements. We found there were no breaches of regulation and improvements had been made in the required areas. The overall rating for Ash Grove Care Home has been changed to ‘Good’. We will review the overall rating of ‘Good’ at the next comprehensive inspection, where we will look at all aspects of the service and to ensure the improvements have been sustained.

Ash Grove Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Ash Grove Care Home provides accommodation and personal care for up to 30 people in one adapted building. At the time of the inspection there were 14 people living there. People living at the home were older people, some of who were living with dementia. They had a range of needs associated with old age and their health.

There was no registered manager at the service at the time of the inspection. However, there was a manager working at the home and responsible for the day to day running of the service. They had commenced the registration process with the Care Quality Commission and their registration was confirmed the week following this inspection. 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 this inspection we found significant improvements had been made and the provider is now meeting the regulations. However, time is needed to fully embed these improvements into everyday practice and ensu

Inspection areas



Updated 21 March 2018

Ash Grove Care Home was safe.

There were enough staff to meet people's needs.

Risk assessments were in place and staff had a good understanding of the risks associated with the people they looked after.

There were systems to ensure medicines were ordered, stored administered and disposed of safely.

Staff understood the procedures to safeguard people from the risk of abuse.



Updated 21 March 2018

Ash Grove Care Home was effective.

Staff received the training and support they needed to enable them to meet the needs of people who lived at the home.

People were given choice about what they wanted to eat and drink and received food that they enjoyed.

The manager and staff understood their responsibilities in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

People were supported to maintain good health and had access to external healthcare professionals such as the GP when they needed it.



Updated 21 March 2018

Ash Grove Care Home was caring.

People�s privacy and dignity were respected.

Staff knew people well and treated them with kindness, understanding and patience.

People were supported to make their own decisions and choices throughout the day.



Updated 21 March 2018

Ash Grove Care Home was responsive.

People received care that was person centred and met their individual needs and choices. Staff had a good understanding of providing person-centred care.

There was a range of activities taking place and people were supported to do what they chose throughout the day.

There was a complaints policy and people and visitors told us they would raise any concerns with staff.


Requires improvement

Updated 21 March 2018

Improvements had taken place since our last inspection in relation to people�s records and the quality assurance system. However, these needed time to be fully embedded into practice.

The manager promoted an inclusive and open culture.

There were effective systems to assure quality and identify any potential improvements to the service being provided.