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CQC report explained · a nursing home, run by Barchester Healthcare
Ashlar House
The Plain, Epping, CM16 6TY
Goodpublished 22 November 2023, 2 years ago
Rated Good: inspectors found the service performing well and meeting their expectations.
The five questions inspectors ask
- Safe?
- Good
- People were protected from avoidable harm. Inspectors found enough staff, safe medicines procedures, suitable risk assessments, infection control measures and systems for learning from incidents.
- Effective?
- Good
- This key question was not inspected during this visit. Its rating was carried over from the previous inspection.
- Caring?
- Good
- This key question was not inspected during this visit. Its rating was carried over from the previous inspection.
- Responsive?
- Good
- This key question was not inspected during this visit. Its rating was carried over from the previous inspection.
- Well-led?
- Good
- Inspectors found effective audits, regular meetings and supervision, and a manager who listened to people, relatives and staff and worked with health professionals.
The latest report, explained
What inspectors found, November 2023
Rated Good; inspectors found safe, well-managed care, with minor improvements needed to recruitment files.
This was an unannounced, focused inspection. Inspectors visited on 8 November 2023 and reviewed Safe and Well-led. They spoke with people living there, relatives, staff and health professionals, and checked care, medicines, recruitment and other records.
The home was rated Good overall, with Good ratings for Safe and Well-led. Inspectors found enough trained staff, safe medicines systems, suitable risk assessments and effective infection control. People and relatives said they felt safe and spoke positively about the care.
The main shortfall was in staff recruitment records. Some files did not contain proof of address, so inspectors made a recommendation to improve these records. The Good rating was unchanged from the previous inspection, published in May 2018, but the other key questions were not inspected in this visit.
What inspectors praised
Enough trained staff
Staff numbers and skills matched people's needs. Staff received induction, training and shadowing before working independently.
“The numbers and skills of staff matched the needs of people using the service.” from the report
Safe medicines
Medicines were given as prescribed and recorded. Staff had training and competency checks, and medicines were stored securely.
“People were given their medicines safely and as prescribed, and it was recorded on their medicine administration record.” from the report
People felt safe
People and relatives told inspectors they felt safe. Staff understood safeguarding and knew how to report concerns.
“People using the service and their relatives told us they felt safe.” from the report
Open management
The home used meetings, surveys, audits and supervision to hear views and make improvements. Relatives and staff described management as approachable and supportive.
“The service used this information to implement action plans and make improvements.” from the report
Good infection control
Inspectors found the environment clean, with suitable supplies of protective equipment and regular infection-control checks.
“The environment was clean, and people confirmed regular cleaning took place.” from the report
What inspectors were concerned about
Recruitment records
needs fixingSome staff recruitment files were missing proof of address. Inspectors recommended that recruitment checks and documents should be managed more consistently.
“Minor improvements were needed to staff recruitment files to ensure they meet the regulations.” from the report
Questions to ask them, based on this report
- 01Have all staff recruitment files now been updated to include proof of address and the other required documents?
- 02How do you check that staff are safe to work with people before they start?
- 03How many staff are on duty on each shift, and how do their skills match the needs of people living here?
- 04How are medicines given, checked and audited, including medicines given when needed?
- 05What ratings did the previous inspection give for Effective, Caring and Responsive?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried over from the previous inspection. This explanation was written from the published report of 22 November 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
The story over the years
Every inspection of Ashlar House
4 rated inspections over 8 years: the service has held its Good rating throughout.
- November 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- April 2017Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- August 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 15 February 2011.
Ratings and report dates from the Care Quality Commission. A service can also be visited without a new rating being published, so the timeline shows published inspections, not every contact the CQC has had with the service.
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