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Ashbrook Court Care Home Requires improvement

The provider of this service changed - see old profile

Inspection Summary

Overall summary & rating

Requires improvement

Updated 1 November 2019

About the service

Ashbrook Court Care Home is a residential care home providing personal and nursing care to 63 people aged 65 and over at the time of the inspection. This also includes living with dementia. The service can support up to 70 people in one adapted building. The care home is unitised and supports people across four separate units, which have separated adapted facilities.

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

Medication practices were not safe, and people did not always receive their medicines as prescribed. People told us they were safe. Suitable arrangements were in place to protect people from abuse and avoidable harm. Staff understood how to raise concerns and knew what to do to safeguard people. Risks to people were identified and assessed to keep them safe. Sufficient numbers of staff were available to support people living at Ashbrook Court Care Home and to meet their needs. Recruitment practices were now robust to make sure the right staff were recruited. People were protected by the prevention and control of infection. Findings from this inspection showed lessons were being learned and improvements made when things go wrong.

Staff received appropriate training and newly appointed staff received an induction. The dining experience for people using the service was positive and much improved. People received enough food and drink to meet their needs. People were supported to access healthcare services and to receive ongoing healthcare support as required. The service worked with other organisations to enable people to receive effective care and support. 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.

People and those acting on their behalf told us they were treated with care, kindness, respect and dignity. Staff had a good rapport and relationship with the people they supported, and observations demonstrated what people told us.

Though each person had a plan of care detailing their care needs and how these were to be met by staff, shortfalls were identified with some aspects of record keeping. Care plans relating to people’s end of life care arrangements were not sufficiently detailed. The service was not fully compliant with the Accessible Information Standard to ensure it meets people’s communication needs. People and those acting on their behalf were confident to raise issues and concerns and felt listened to, but improvements were required to ensure the investigation of complaints was robust.

Governance arrangements were much improved, but progress was still required to make sure improvements made were sustained in the longer term.

We have made recommendations about record keeping and complaints management.

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

Rating at the last inspection

The last rating for this service was requires improvement (published March 2019) and there were three breaches of regulation. This referred specifically to Regulation 9 [Person-centred care], Regulation 12 [Safe care and treatment] and Regulation 17 [Good governance]. Enforcement action was completed whereby the Care Quality Commission imposed conditions on the provider’s registration. The provider completed an action plan after the last inspection to show what they would do and by when to improve. This was updated each month with a copy forwarded to the Care Quality Commission.

The service remains rated requires improvement, but the Commission acknowledges significant improvements have been made. This service has been rated requires improvement for the last three consecutive inspections. At this inspection we found improvements had been made and the provider was in breach of one regulation. This related to medicines management.

Why we inspected

This was a planned

Inspection areas


Requires improvement

Updated 1 November 2019

The service was not always safe.

Details are in our safe findings below.



Updated 1 November 2019

The service was effective.

Details are in our effective findings below.



Updated 1 November 2019

The service was caring.

Details are in our caring findings below.


Requires improvement

Updated 1 November 2019

The service was not always responsive.

Details are in our responsive findings below.


Requires improvement

Updated 1 November 2019

The service was not always well-led.

Details are in our well-Led findings below.