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Archived: Three Ashes Residential Care Home Requires improvement

The provider of this service changed - see old profile

The provider of this service changed - see new profile

Inspection Summary

Overall summary & rating

Requires improvement

Updated 23 May 2018

This unannounced inspection took place on 13 and 16 April 2018.

Three Ashes Residential Care Home is a ‘care home’ for up to 11 older people, some of whom were living with a physical or sensory disability. 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. Three Ashes is registered for older people living with dementia, physical disability and/or sensory impairment. At the time of this inspection 9 people were living there.

Accommodation at Three Ashes is provided over two floors with bedrooms located on the ground and first floors. The ground floor was wheelchair accessible. A stair lift was fitted to assist people with limited mobility to access the first floor. Most bedrooms had en-suite facilities with a shower and a communal bathroom was located on the first floor. Two lounge areas, one in a large conservatory overlooking the extensive gardens, were located on the ground floor and a dining area was situated, open plan, between the two lounges.

Three Ashes has changed ownership twice since our last inspection in November 2015 but the legal entity remained the same. At our last inspection in 2015 the service was rated Good. The home has been under the current ownership since August 2017. Staff working at Three Ashes at the time of the sale transferred across to the new owner, remaining in post at the home.

There had been no registered manager in post at Three Ashes since February 2018. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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. The service was being managed by the provider’s representative until a new registered manager was appointed.

During this inspection we identified two breaches of the Health and Social Care Act 2005 (Regulated Activities) Regulations 2014. The service has been rated ‘Requires Improvement’ overall.

People were not always supported by staff who had received the training and support they needed to carry out their duties effectively. The systems and processes in place to monitor the safety and quality of the services provided to people were not always effective in identifying and addressing shortfalls. Complete records of the care and treatment provided to people had not always been kept. We recommend that the service review good practice guidance for managing medicines in care homes and take action to update their practice accordingly.

Risks to people were managed with the support and guidance of health professionals to ensure people remained safe. There were enough suitable staff to meet people's needs. Staff worked openly with other agencies to safeguard people from harm. The building and equipment were appropriately maintained and people were protected from risks associated with cross infection.

People benefitted from a stable and caring staff team who knew them well. They were supported to access appropriate health care. Staff took a personalised approach to meeting people’s needs and outcomes for people were good. People’s preferences were taken into account by staff when providing care and people were offered choices in their day to day lives. People’s privacy was respected and they were treated with dignity and kindness. People were supported to maintain relationships with others who were important to them. People received good end of life care.

People's views about the service they received were sought and these were used to improve the service. People were able to raise complaints and these were responded to promptly. The culture at the home was open and transparent. Staff and managers worked together to provide a fri

Inspection areas



Updated 23 May 2018

The service was safe.

People received their medicines as prescribed.

People were safeguarded from the risk of being supported by unsuitable staff because robust recruitment checks were completed and staff knew how to report safeguarding concerns.

People were protected against health and well-being related risks and there were enough staff to meet their support needs.


Requires improvement

Updated 23 May 2018

The service was not always effective.

People were not always supported by staff who had the training and knowledge to meet their needs effectively.

Improvement was needed to ensure the requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS) were met consistently.

People were supported to make decisions about their day to day care.

People's health and nutritional needs were met and they had access to health and social care professionals.



Updated 23 May 2018

The service was caring.

People were supported by staff who were caring and sensitive to their needs.

People were treated with respect, kindness and compassion. People and their close relatives were listened to and were involved in decisions about their care.

Staff understood how to communicate with people.

People's dignity and privacy was maintained and their independence in daily activities was promoted.



Updated 23 May 2018

The service was responsive.

People received personalised care and were routinely consulted about the support they received.

Staff knew people well and worked flexibly to meet their needs. People were enabled to maintain relationships with those who mattered to them.

People were able to raise complaints and these were responded to.

People's end of life wishes were explored with them.


Requires improvement

Updated 23 May 2018

The service was not always well led.

Systems in place to monitor and make improvements to the service were not sufficiently robust to identify and address all required improvements.

Complete records of the care and treatment provided to people had not always been kept.

The provider and management team worked openly with others, seeking their feedback, to improve the service.

People benefitted from an inclusive service where they were valued as individuals.