Ashdale Care Home

Social Care Org · East Midlands

Overall Rating
Inadequate Last inspected 15 November 2023
Domain Ratings
Safe
Inadequate
Effective
Requires Improvement
Caring
Good
Responsive
Good
Well-led
Inadequate

View Full CQC Report

13 must-do actions

Must-Do Actions (13)

Legal requirements based on regulation breaches identified during inspection.

Must Do
Safe
The provider did not have suitable equipment to support people who were at risk of falling out of bed.
Regulation 12 (Safe care and treatment)
At the last inspection, we found people who were at risk from falls from bed. At this inspection, we were not assured sufficient improvements had been made. The provider's policy stated that if the person was unable to use bedrails, then alternative equipment was available. For example, a padded matt …
Must Do
Safe
The provider had not completed routine water maintenance. This means there is an increased risk from legionella bacteria, which can cause serious ill health.
Regulation 12 (Safe care and treatment)
People living at the care home would be at risk of Legionnaires disease. Since the last inspection, the provider had not completed routine maintenance of the water systems. This means there is an increased risk of waterborne legionella bacteria. Legionella bacteria can result in serious ill health if people then …
Must Do
Safe
The fire alarm system had a fault, this had not been investigated or resolved.
Regulation 12 (Safe care and treatment)
At the last inspection, we identified a fault with the fire alarm panel. At this inspection, the provider had not taken action to investigate or resolve this. This meant we were not assured people would be safe in the event of a fire.
Must Do
Safe
The radiators in the care home did not heat the home enough. During the inspection, the provider was unable to resolve this heating issue.
Regulation 12 (Safe care and treatment)
The radiators in the care home did not heat the home enough. During the inspection, the provider was unable to resolve this heating issue. We were therefore not assured that people could live in a home that was a safe temperature for good health.
Must Do
Safe
We were not assured staff were adequately trained. At the last inspection, we identified concerns with staff skills, limited action had been taken to provide further training.
Regulation 18 (Staffing)
We were not assured staff were adequately trained. At the last inspection, we identified concerns with staff skills, limited action had been taken to provide further training. If people used the care home, they would be supported by staff without the appropriate skills.
Must Do
Safe
People using the care home could be at risk of choking. Only 1 staff member had received relevant training on how to support people's swallowing needs, there was a lack of guidance in the kitchen for staff to follow.
Regulation 12 (Safe care and treatment), Regulation 18 (Staffing)
People using the care home could be at risk of choking. Only 1 staff member had received relevant training on how to support people's swallowing needs, there was a lack of guidance in the kitchen for staff to follow.
Must Do
Safe
At the last inspection, staff did not have clear care plan guidance on how to support people. The provider gave inspectors an example of a 'dummy care plan'. However, this example document lacked guidance on what information would be within care plans to ensure staff had clear guidance to follow.
Regulation 9 (Person-centred care), Regulation 12 (Safe care and treatment)
At the last inspection, staff did not have clear care plan guidance on how to support people. The provider gave inspectors an example of a 'dummy care plan'. However, this example document lacked guidance on what information would be within care plans to ensure staff had clear guidance to follow. …
Must Do
Safe
The provider was not able to provide a clear list of employed staff names, their recruitment details or what training they had received.
Regulation 19 (Fit and proper persons employed), Regulation 18 (Staffing)
The provider was not able to provide a clear list of employed staff names, their recruitment details or what training they had received. We were therefore not assured that people living at Ashdale Care Home would be supported by suitable staff.
Must Do
Well-led
The provider did not have a clear action plan to describe what their ongoing plans were. This is because the action plan did not have expected completion dates, or which staff member would be responsible for taking the planned action. The provider had implemented new policies. However, these policies lacked detail.
Regulation 17 (Good governance)
The provider did not have a clear action plan to describe what their ongoing plans were. This is because the action plan did not have expected completion dates, or which staff member would be responsible for taking the planned action. We were therefore not assured that there was a clear …
Must Do
Well-led
Clear governance structures had not been implemented. For example, we were told that people would be weighed weekly. However, there was no clear documentation on how this would be effectively implemented and reviewed.
Regulation 17 (Good governance)
Clear governance structures had not been implemented. For example, we were told that people would be weighed weekly. However, there was no clear documentation on how this would be effectively implemented and reviewed. We were therefore not assured that people's weight loss would be effectively overseen.
Must Do
Well-led
There was no registered manager in place. The previous registered manager had left the role in June 2023. It is a legal requirement for Ashdale Care Home to have a registered manager in place, as they are legally accountable for the running of the service.
Regulation 7 (Requirements relating to registered managers)
There was no registered manager in place. The previous registered manager had left the role in June 2023. It is a legal requirement for Ashdale Care Home to have a registered manager in place, as they are legally accountable for the running of the service.
Must Do
Well-led
Following the inspection, we were advised that the management structure would change. We were sent a new planned organisational structure chart. This did not provide us with sufficient assurances, as there were 3 vacancies in this chart and no clarity on when this managerial change would occur.
Regulation 17 (Good governance)
Following the inspection, we were advised that the management structure would change. We were sent a new planned organisational structure chart. This did not provide us with sufficient assurances, as there were 3 vacancies in this chart and no clarity on when this managerial change would occur.
Must Do
Effective
At the last inspection, the principles of the mental capacity act were not followed. At this inspection, documentation had not changed, and a member of the management team advised that similar processes would be followed.
Regulation 9 (Person-centred care), Regulation 11 (Need for consent)
At the last inspection, the principles of the mental capacity act were not followed. At this inspection, documentation had not changed, and a member of the management team advised that similar processes would be followed. This meant we were not assured improvements in the MCA would be effectively implemented.

Previous Inspection (15 November 2023)

Rating: Inadequate Type: Focused inspection Actions: 4 must-do
4 repeated
Location Details
CQC ID: 1-1007050476
Local Authority: Nottinghamshire
Region: East Midlands
Inspection Report
Type: Targeted inspection
Date: 6 January 2024
Rating: Inadequate
Actions: 13 must-do
AI-extracted 17 Feb 2026