Ashbourne House - Torquay

Social Care Org · South West

Overall Rating
Inadequate Last inspected 29 September 2016
Domain Ratings
Safe
Inadequate
Effective
Requires Improvement
Caring
Requires Improvement
Responsive
Inadequate
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 arrangements for staffing did not always ensure people's needs were met. There were not enough staff employed to meet people's needs.
Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
The arrangements for staffing did not always ensure people's needs were met. There were not enough staff employed to meet people's needs.
Must Do
Safe
Service users were not protected from abuse because there were ineffective systems in place to implement safeguarding recommendations. There was a limited understanding from staff about safeguarding procedures.
Regulation 13 HSCA RA Regulations 2014 Safeguarding service users from abuse and improper treatment
Service users were not protected from abuse because there were ineffective systems in place to implement safeguarding recommendations. There was a limited understanding from staff about safeguarding procedures.
Must Do
Safe
The provider did not take responsive action in order to keep people safe. People's risks associated with their care had not always been assessed and documented to help staff know how to mitigate risks associated with people's care.
Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
The provider did not take responsive action in order to keep people safe. People's risks associated with their care had not always been assessed and documented to help staff know how to mitigate risks associated with people's care.
Must Do
Safe
People's medicines were not always stored safely. People did not always have accurate records and information in place relating to their medicines. Monitoring systems were not effective.
Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
People's medicines were not always stored safely. People did not always have accurate records and information in place relating to their medicines. Monitoring systems were not effective.
Must Do
Safe
People were not protected by infection control practices. The staff and provider did not have up to date knowledge in respect of infection control practices.
Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
People were not protected by infection control practices. The staff and provider did not have up to date knowledge in respect of infection control practices.
Must Do
Effective
Care and treatment of service users was not always provided with the consent of the person. Service users, who lacked capacity, did not always have their human rights protected in accordance with the Mental Capacity Act 20015 (MCA).
Regulation 11 HSCA RA Regulations 2014 Need for consent
Care and treatment of service users was not always provided with the consent of the person. Service users, who lacked capacity, did not always have their human rights protected in accordance with the Mental Capacity Act 20015 (MCA).
Must Do
Effective
People's nutritional needs were not always met in line with their needs, wishes and preferences. People's care plans were not always reflective of how their nutritional needs should be met.
Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
People's nutritional needs were not always met in line with their needs, wishes and preferences. People's care plans were not always reflective of how their nutritional needs should be met.
Must Do
Caring
Service users were not always treated with dignity and respect.
Regulation 10 HSCA RA Regulations 2014 Dignity and respect
Service users were not always treated with dignity and respect.
Must Do
Caring
People were not involved in making decisions about their care and support.
Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
People were not involved in making decisions about their care and support.
Must Do
Responsive
People's care plans did not meet their needs and were not reflective of their wishes and preferences. People's care plans were not always effectively reviewed to ensure they were reflective of the care being delivered.
Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
People's care plans did not meet their needs and were not reflective of their wishes and preferences. People's care plans were not always effectively reviewed to ensure they were reflective of the care being delivered.
Must Do
Responsive
The provider did not effectively record, handle and respond to complaints.
Regulation 16 HSCA RA Regulations 2014 Receiving and acting on complaints
The provider did not effectively record, handle and respond to complaints.
Must Do
Well-led
The provider did not have effective systems and processes in place to ensure the ongoing monitoring and quality of the service. People's feedback was not obtained to improve and develop the service. The provider did not act on feedback from health and social care professionals in order to improve the service for people.
Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
The provider did not have effective systems and processes in place to ensure the ongoing monitoring and quality of the service. People's feedback was not obtained to improve and develop the service. The provider did not act on feedback from health and social care professionals in order to improve the …
Must Do
Well-led
The provider had failed to notify the Commission without delay of all significant events in line with their legal obligations.
Regulation 18 Registration Regulations 2009 Notifications of other incidents
The provider had failed to notify the Commission without delay of all significant events in line with their legal obligations.
Location Details
CQC ID: 1-111339076
Local Authority: Torbay
Region: South West
Inspection Report
Type: Comprehensive inspection
Date: 29 September 2016
Rating: Inadequate
Actions: 13 must-do
AI-extracted 17 Feb 2026