Ashmore Nursing Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

The service did not have an effective quality assurance system which meant that shortfalls were not always identified or addressed promptly. Issues were identified at the last inspection and while some improvements have been made, the provider remains in breach of the regulations in relation to good governance. Despite the concerns about the impact of low staffing, people and relatives told us that staff were kind, and the registered manager tried to resolve issues on an individual basis.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The registered manager worked both as a manager and a registered nurse. They were highly visible and provided clear direction to staff. Staff told us that the registered manager was supportive and good to work with. They had worked at the service for many years and knew the needs of people who used the service. Relatives told us that they were approachable and would listen to their concerns and try and rectify any issues on an individual basis.

The registered manager had recently appointed a new deputy manager to assist them in the day-to-day management of the service. The service had been experiencing significant staffing shortfalls and as a result the registered manager and deputy manager prioritised directly providing nursing care. This impacted on the management oversight of the service.

Staff spoke positively about the approachability of the registered manager but were not confident that speaking up about the staffing shortfalls would make a significant difference as the issues and their concerns were long standing.

Dates of staff appraisals and supervisions were provided to demonstrate that staff had the opportunity to raise issues. Team meetings were not frequent with the most recent taking place six months prior to the inspection. Staff described informal discussions taking place between staff. Questionnaires on the quality of care were available for relatives and people to complete, and a small number had been completed, however most relatives we spoke with could not recall completing a questionnaire. Relatives told us that they were not aware of any recent relatives or resident meetings

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The registered manager told us that they worked alongside staff and described some of the processes they had in place to provide oversight, but these were not always written down. Statutory notifications to CQC had not always been made for example where people had fallen or where the service had raised safeguarding alerts. Once we raised these issues with the registered manager they responded and submitted the required notifications, however, should have been submitted in a timely way in line with the providers regulatory responsibilities.

Audits were undertaken, but these were not well developed and were not always fully effective at identifying or rectifying shortfalls. Some were completed by the registered manager and others delegated to other staff. There was no evidence of effective scrutiny at provider level. The checks on the environment, medicines and records had not always identified where there were problems. There was no evidence of direct impact on people but there were potential risks. For example, having no locks on external gates or no risk assessment for the stairs. One person had oxygen in their room, and there was no sign on the door to alert first responders to this risk. Equipment for measuring people’s weights was broken and had been sent for repair but there were no interim arrangements and people had not been weighed some months prior to our visit. Once we raised these issues with the registered manager, they told us that they would take immediate action however the systems used had not identified the concerns independently.

Most people told us that they choose the service as they valued its location and meant that they could maintain relationships which were important to them and access local services.

Staff reported positively on the relationship the service had with other professionals including the tissue viability nurse, speech and language service and the local GP. The registered manager supported staff to access learning to develop their skills and knowledge. Staff told us that there were a range of resources open to them as well as access to practical learning opportunities to accommodate all types of learning Processes were in place to ensure information was obtained regarding people’s needs prior to them being admitted to the service.

Professional partners did not raise any specific concerns about the leadership of the service.

The use of questionnaires and surveys was not well developed with staff or external agencies.

Issues such as problems in recruiting and retaining staff and broken equipment were acknowledged by the management of the service. However, they were identified as a short-term issue which needed to be resolved rather than one which required a longer-term strategy and investment. The registered manager described some of the improvements that they had made since the last inspection which included investment in a new electronic care planning and recording system and a new entrance to the home which improved security.

Whilst improvements had been made, all the requirements made at the last inspection had not been met in full. This indicates that systems for learning and improving the service had not always been effectively implemented.