- Care home
Ashlett Dale Rest Home
Report from 22 May 2025 assessment
Contents
Ratings
Our view of the service
Date of Assessment: 04 December 2024 to 20 December 2024.
This assessment was carried out in response to concerns about how falls were managed, including risk assessment and incident reporting. There were also concerns relating to staff training and competency and knowledge of mental capacity issues.
The registered manager promoted a learning culture and people could raise concerns. However, this would be better supported through more robust systems and processes of management.
Staff received training in safeguarding. Recent safeguarding referrals had been made appropriately.
Care plans and risk assessments were sometimes generic and did not always contain clear guidance for staff. Follow up actions were not always recorded or monitored effectively.
Systems and procedures for recruiting new staff were not robust. The registered manager told us staff were supervised whilst they were waiting for their full DBS to come through but could not produce any evidence of this in relation to 2 staff whose records we reviewed. The registered manager informed us of the actions they are taking to address this. Staff received training and completion of this was monitored. Competency checks did not always take place or were not recorded.
People’s medicines were mostly managed safely. However, there was some lack of sufficient individualised and personalised information within people’s medicines records.
When providing support, staff sought people’s consent. Improvements were being made to the way issues around consent were recorded.
We received positive feedback from external health and social care professionals about how the service worked in partnership with them.
Systems and processes to assess, monitor and improve the quality and safety of the service had not been established and operated effectively. Statutory notifications had not always been sent to CQC when required. These are being submitted retrospectively.
During our visits, the registered manager was responsive to any issues we identified. Throughout the inspection, we observed some examples of effective care practices. We saw evidence of ongoing improvements being made to the premises.
We found 2 breaches of the regulations in the areas of staffing and good governance.
We have asked the provider for an action plan in response to the concerns found at this assessment.
People's experience of this service
People we spoke with were very positive about the staff and their ability to meet their needs. One person commented “It’s lovely here. Everything is good. If you said you were unhappy or something was wrong, they would sort you out”. Another person told us, “The staff are wonderful. They’ve been very accommodating and couldn’t be nicer”.
Staff promoted people’s independence and personal choice. A person who was on a respite stay at the home told us, “I manage my medication myself. Staff have given me a safe in my room with a key”. They said, “Staff monitor this. They ask me if I’ve taken it”. Another person told us, “Nobody pushes you to do anything. They ask you”, and “You come down when you’re ready and if you’re not feeling well enough, they’ll give you your meal upstairs”.
Many relatives said they were happy with the service, with some confirming their involvement in care plans. Relatives said the managers were approachable and welcoming.
While people expressed general satisfaction with their care and support, our assessment found some elements of care did not meet the expected standards.