Ashcroft House - Leeds

Social Care Org · Yorkshire & Humberside

Overall Rating
Inadequate Last inspected 5 February 2024
Domain Ratings
Safe
Inadequate
Effective
Inadequate
Caring
Inadequate
Responsive
Requires Improvement
Well-led
Inadequate

View Full CQC Report

20 must-do actions
2 should-do actions

Must-Do Actions (20)

Legal requirements based on regulation breaches identified during inspection.

Must Do
Safe
The provider must comply with Regulation 12: Safe Care and Treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Regulation 12 (Safe care and treatment)
People were not protected from risks because the provider had failed to identify or sufficiently plan for risks and guide staff on how to reduce and minimise these. This placed people at risk of significant harm. People were not protected from the risk of choking. There was no sufficiently detailed …
Must Do
Safe
The provider must comply with Regulation 12: Safe Care and Treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Regulation 12 (Safe care and treatment)
Medicines were not always administered safely and in line with the instructions of the prescriber. We found medicines which had been signed for but not given to people in a returns box which were due to be destroyed. Some people had not received their medicines for consecutive days. Staff responsible …
Must Do
Safe
The provider must comply with Regulation 12: Safe Care and Treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Regulation 12 (Safe care and treatment)
At the last inspection the service was rated requires improvement and the provider was told to make improvements in a number of areas. At this inspection we found the provider had not made improvements and the service had deteriorated in quality. Two people had come to harm and the provider …
Must Do
Safe
The provider must comply with Regulation 13: Safeguarding people from abuse or avoidable harm of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Regulation 13 (Safeguarding people from abuse or avoidable harm)
People using the service were not protected from the risk of abuse. Staff had received training in safeguarding. However, we found an incident had occurred and none of the staff present reported this to the registered manager or made a safeguarding referral. This meant we were not assured that staff …
Must Do
Safe
The provider must comply with Regulation 18 HSCA RA Regulations 2014 Staffing.
Regulation 18 (Staffing)
There were not enough staff to support people safely. People told us there were not enough staff to support them when they needed it. One person said, 'There is not enough staff and sometimes you can't find anybody and if there is two on you can't find anybody.' There were …
Must Do
Effective
The provider must comply with Regulation 14: Meeting nutrition and hydration needs of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Regulation 14 (Meeting nutrition and hydration needs)
People at risk of malnutrition were not effectively supported to manage this risk. They were not weighed regularly, and we noted significant gaps of several months for people at risk of weight loss. One person who was underweight had not been weighed since September 2023. The hospital weighed this person …
Must Do
Effective
The provider must comply with Regulation 9: Person Centred Care of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Regulation 9 (Person Centred Care)
People's needs were assessed when they came to live at the service. However, these were not always reassessed on an ongoing basis to monitor whether their needs were changing. Care plans did not reflect best practice guidance such as that provided by the National Institute of Health and Care Excellence …
Must Do
Effective
The provider must comply with Regulation 9: Person Centred Care of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Regulation 9 (Person Centred Care)
People's individual needs were not met by the adaption, design and decoration of the premises. Many of the corridors were plain which made it was harder for people living with dementia to navigate around. There was nothing identifiable on many people's bedroom doors so they could identify their bedroom easily. …
Must Do
Effective
The provider must comply with Regulation 11 HSCA RA Regulations 2014 Need for consent.
Regulation 11 (Consent to Care and Treatment)
Staff did not have a good understanding of the Mental Capacity Act and how they should apply this in their role. People were not always enabled to make choices according to their ability and to maintain control of their own lives. People told us staff did not always let them …
Must Do
Caring
The provider must comply with Regulation 10: Dignity and Respect of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Regulation 10 (Dignity and Respect)
The service was not caring. Whilst some staff were intuitively caring, the provider and registered manager had allowed people to be continually exposed to the risks of poor and inappropriate care and had failed to take action to improve standards of care. This does not demonstrate a caring service. People …
Must Do
Caring
The provider must comply with Regulation 9: Person Centred Care of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Regulation 9 (Person Centred Care)
People were not always supported to express their views and make decisions about their care. Care records did not consistently reflect people's thoughts, feelings or wishes on their care. Care records were not person centred enough and did not reflect people as individuals. There was not always evidence of people …
Must Do
Caring
The provider must comply with Regulation 10: Dignity and Respect of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Regulation 10 (Dignity and Respect)
People's privacy, dignity and independence were not always respected and promoted. People and relatives told us there had been a long-term issue with the laundry which meant they did not receive their own clothes from the laundry and other people's clothes were put in their wardrobes and offered to them …
Must Do
Responsive
The provider must comply with Regulation 9: Person Centred Care of the Health and Social Care Act 2008 (Regulated Activities) Regulated Activities.
Regulation 9 (Person Centred Care)
People were not supported as individuals, in line with their needs and preferences. Care records were not personalised to reflect people's diversity and individuality. Some preferences were included, but these were often limited and there was no information about people's routines or how they wished for their care to be …
Must Do
Responsive
The provider must comply with Regulation 9: Person Centred Care of the Health and Social Care Act 2008 (Regulated Activities) Regulated Activities.
Regulation 9 (Person Centred Care)
The provider was not meeting the Accessible Information Standard. People's communication needs were not fully understood and supported. People's communication methods were not always recorded in their care records. Information was not adapted to ensure people could access it. People living with dementia were not always supported to make visual …
Must Do
Responsive
The provider must comply with Regulation 9: Person Centred Care of the Health and Social Care Act 2008 (Regulated Activities) Regulated Activities.
Regulation 9 (Person Centred Care)
End of life care planning was not sufficiently detailed. For some people, no preferences were recorded. For other people who were in the end stages of their life, there was no information about the complex care they would require at this time to ensure they had a comfortable and pain …
Must Do
Responsive
The provider must comply with Regulation 9: Person Centred Care of the Health and Social Care Act 2008 (Regulated Activities) Regulated Activities.
Regulation 9 (Person Centred Care)
People were not supported to maintain relationships, follow their interests, or take part in activities that were relevant to them. People were largely disengaged with little source of engagement or stimulation available. Care staff told us they did not have time to sit with people and engage with them, and …
Must Do
Well-led
The provider must comply with Regulation 17 Good Governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Regulation 17 (Good Governance)
The provider did not have a system in place to provide person-centred care that achieved good outcomes for people. The culture of the service was not open or positive. People were not supported to live their lives in the way they wanted. People were not consistently protected from the risks …
Must Do
Well-led
The provider must comply with Regulation 17 Good Governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Regulation 17 (Good Governance)
Quality assurance systems did not lead to continual improvement. A system of auditing was in place; however, it was ineffective because they did not always highlight where improvements were needed. Where areas for improvement had been identified, they had not always been addressed or sustained. The provider had been told …
Must Do
Well-led
The provider must comply with Regulation 17 Good Governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Regulation 17 (Good Governance)
Feedback was not consistently sought or acted upon. People and their relatives were given the opportunity to participate in a survey of their views and in meetings. However, meetings were not regularly carried out; meeting minutes were only available for 2 meetings since January 2023. People's feedback had not always …
Must Do
Well-led
The provider must comply with Regulation 17 Good Governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Regulation 17 (Good Governance)
The provider did not always work effectively in partnership with others. Where advice had been provided by external healthcare professionals, this did not always lead to changes in care planning for people and care delivery. The provider had been advised against admitting one person to the service by the local …

Should-Do Actions (2)

Recommended improvements to enhance service quality.

Should Do
Effective
We recommend that instructions received by external healthcare professionals be written into care planning and that staff are made aware of these instructions so they can be fully implemented.
Should Do
Effective
We recommend that the provider ensures better oversight of staff competency and monitors staff practice more closely to identify areas for improvement.

Previous Inspection (9 July 2022)

Rating: Requires Improvement Type: Focused inspection Actions: 2 must-do , 1 should-do
3 repeated
Location Details
CQC ID: 1-109574569
Local Authority: Leeds
Region: Yorkshire & Humberside
Inspection Report
Type: Comprehensive inspection
Date: 5 February 2024
Rating: Inadequate
Actions: 20 must-do , 2 should-do
AI-extracted 17 Feb 2026