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Inspection Summary

Overall summary & rating


Updated 15 June 2018

This inspection was unannounced and completed on the 22 and 23 May 2018. At our last inspection in August 2016 we found the service required improvement in the key questions safe and effective. At this inspection the required improvement had been made so the service is rated good.

Ashcombe 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. Ashcombe accommodates 31 people in one adapted building. At the time of our inspection 26 people were living at the service.

Ashcombe is a two storey building with a lift to access the upper floor. The home has communal areas such as a lounge and small conservatory. There is a small secure garden and a sheltered seating area at the front of the property with garden furniture.

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.

Medicines were managed safely. Registered nurses were responsible for medicines management and were assessed and trained by the provider. People had individual medicines administration records that had been completed in full with no unexplained gaps.

Staff had been recruited safely. There were sufficient staff available to people and staff rotas demonstrated consistency. Staff were aware of their responsibility to keep people safe from harm and told us how they would report any concern. Staff were confident that the registered manager would take appropriate action.

The environment was clean and well maintained. All equipment was serviced regularly and safety systems were checked and tested. Fire systems were tested weekly and staff practiced fire drills monthly.

Risks had been identified and assessed. There were safe systems in place which were reviewed on a regular basis. If people required equipment to keep them safe such as hoists or bed rails this had been sourced and were available.

Staff were trained in a variety of topics relevant to their role and all new staff had an induction. Supervision was provided on a regular basis, all staff we spoke with told us they felt well supported in their role. There were daily meetings for the heads of department and monthly team meetings with minutes produced.

People had regular food and drinks. There was support provided for people to eat if needed. The dining experience was relaxed and unhurried. The tables were laid with tablecloths, napkins and flowers to support a positive dining experience. The chef served all meals when possible so they could monitor satisfaction levels.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. Where people had their liberty restricted, the service had completed the related assessments and requested the authorisation from the local authority.

The environment had been refurbished and improved in many areas. The registered manager had also submitted requests to improve more areas and was waiting for approval from the provider. Some people’s rooms had been updated with decoration and new furniture.

We observed many positive social interactions which demonstrated that staff were kind and caring. People’s privacy and dignity was promoted and respected by all staff. Visitors were welcomed and there was opportunity for them to stay and enjoy a meal with their relatives.

People had individual care plans that were person centred and reviewed regularly. Care plans detailed people’s needs and how the support was to be provided.

Inspection areas



Updated 15 June 2018

The service was safe.

People's medicines were stored safely and administered by staff that were trained and assessed as competent.

Risks were identified, assessed and managed safely. Risk assessments were reviewed regularly.

Staff were recruited safely. There was sufficient staff available to people and levels of staff were consistent. Staff were aware of the different types of abuse and how to report any concerns.

The service was clean and well maintained. Equipment was serviced regularly.



Updated 15 June 2018

The service was effective.

People's needs were assessed and if needed referrals were made to healthcare professionals.

People had access to food and drinks and the support needed to eat well. The dining experience was supported by all staff at the service and was relaxed and unhurried.

Staff were supported with regular supervision and had access to a variety of training.

The environment had been improved in some areas. There were also plans for further refurbishment.



Updated 15 June 2018

The service was caring.

Staff treated people with kindness and respected their privacy and dignity. We observed many positive social interactions between people and staff.

People told us all of the staff were caring.

Visitors were welcomed to the service with no restrictions. There were refreshments available so visitors could help themselves.

People were involved in their care. There were regular resident meetings which were well attended.



Updated 15 June 2018

The service was responsive.

People had individual, personalised care plans which were reviewed regularly.

There was a structured activity programme in place for every day. People told us they enjoyed the activities on offer.

The service had a complaints procedure, complaints were recorded and logged with detail of the response.

End of life care was provided with support from local healthcare professionals.



Updated 15 June 2018

The service was well-led.

There was a registered manager in post who was a visible presence. They were well known to people and their relatives.

There was a positive culture at the service, people liked living at Ashcombe, staff told us they enjoyed working at the service.

Quality monitoring was robust and carried out by the service and the provider to improve quality and safety.

The service worked in partnership with other agencies and had established community links in the local area.