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Ashbrook Court Care Home Requires improvement

The provider of this service changed - see old profile

We are carrying out a review of quality at Ashbrook Court Care Home. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating

Requires improvement

Updated 15 March 2019

Ashbrook Court Care Home provides accommodation and personal care for up to 70 older people, some of whom who may live with dementia and those who have complex nursing needs. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Our previous comprehensive inspection to the service was on 23 and 24 August 2017. The overall rating of the service at that time was judged to be ‘Requires Improvement’ and no breaches of regulation with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 made.

This inspection was completed on 22 and 23 October 2018 and was unannounced. There were 65 people living at the service.

A registered manager was 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.

Quality assurance checks and audits were not as robust as they should be, as they did not identify the issues we identified during our inspection and had not identified where people were placed at risk of harm and where their health and wellbeing was compromised. Appropriate steps had not been taken to ensure the management team had sufficient oversight of the service which ensured people received safe care and treatment. The lack of managerial oversight at both provider and service level impacted on people, staff and the quality of care provided. The management team were unable to fully demonstrate where improvements to the service were needed, how these were to be and had been addressed; and lessons learned to ensure compliance with regulatory requirements and the fundamental standards.

The management team had not ensured the service was being run in a manner that promoted a caring and respectful culture. Although some staff were attentive and caring in their interactions with people using the service, we observed other interactions which were not respectful or caring and failed to ensure people were treated with respect and dignity. Not all people using the service received appropriate opportunities for meaningful social activities.

The standard of record keeping was poor and care records were not accurately maintained to ensure staff were provided with clear up to date information which reflected people’s current care and support needs. Where people were judged to be at the end of their life, information relating to their end of life care needs were not recorded and not all staff had received appropriate training. Suitable control measures were not always put in place to mitigate risks or potential risk of harm for people using the service as steps to ensure people and others health and safety were not always considered, and risk assessments had not been developed for all areas of identified risk.

Recruitment procedures required improvement to make sure these were robustly completed for all staff employed to ensure safer recruitment practices. Not all staff had received a robust induction and the role of senior members of staff was not effective in monitoring staff’s practice, performance and providing sufficient guidance and support. Training and development was not sufficient in some areas to demonstrate that people's care and support needs were fully understood by staff and embedded in their everyday practice. Staff had not received regular supervision.

People’s capacity to make day-to-day decisions had been considered and assessed. Nonetheless, improvements were required to ensure staff had a better understanding of the main principles of the Mental Capacity Act and how to apply these to their everyday practice, particularly relating to choice

Inspection areas


Requires improvement

Updated 15 March 2019

The service was not consistently safe.

Risks were not identified for all areas of risk. Risks were not suitably managed or mitigated to ensure people’s safety and wellbeing and improvements were required.

Although the deployment of staff appeared to be appropriate in communal lounge areas, comments from people regarding staffing levels was variable and improvements were required to ensure staff spent time with people to talk and to engage with.

Improvements were required to ensure recruitment procedures were reviewed to ensure these are safe.


Requires improvement

Updated 15 March 2019

The service was not consistently effective.

Not all staffs’ knowledge and understanding of training was embedded in their everyday practice. Not all staff had received a robust induction or regular supervision.

The dining experience was variable across the service and improvements were required relating to how people’s nutritional and hydration intake was recorded so that it could be determined if this was satisfactory or not.

Staff’s knowledge and understanding of the Mental Capacity Act 2005 [MCA] and Deprivation of Liberty Safeguards [DoLS] was basic.


Requires improvement

Updated 15 March 2019

The service was not consistently caring.

People using the service did not always receive good quality care or always treated with kindness, respect, dignity and compassion. Care provided was primarily task focused.

Staff did not always effectively communicate with people using the service, particularly people living with dementia.


Requires improvement

Updated 15 March 2019

The service was not consistently responsive.

People did not always receive care and support that was responsive to their individual needs.

Improvements were needed to ensure all of a person’s care and support needs was recorded and the information up-to-date and accurate.

People were not supported to participate in a range of social activities.

Although a record of complaints was maintained, including internal investigations, people and those acting on their behalf did not always feel listened to or confident their concerns would be taken seriously and acted upon.



Updated 15 March 2019

The service was not well-led.

Systems to measure the quality of the service did not identify the concerns and risks to people that we found as part of this inspection.

The views of people and others were sought about the quality of the service provided, however no responses were completed and forwarded to the service.