Source · CQC inspection
Ashbourne House - Torquay
Type Social Care Org
Region South West
Last inspected 29 Sep 2016
Overall rating: Inadequate View full CQC report
Domain ratings
Safe
Inadequate
Effective
Requires Improvement
Caring
Requires Improvement
Responsive
Inadequate
Well-led
Inadequate
Earlier inspection findings
Must-do actions (13)
Must-do action 1 of 13
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.
Must-do action 2 of 13
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.
Must-do action 3 of 13
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.
Must-do action 4 of 13
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.
Must-do action 5 of 13
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.
Must-do action 6 of 13
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).
Must-do action 7 of 13
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.
Must-do action 8 of 13
Must do
Caring
Service users were not always treated with dignity and respect.
Must-do action 9 of 13
Must do
Caring
People were not involved in making decisions about their care and support.
Must-do action 10 of 13
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.
Must-do action 11 of 13
Must do
Responsive
The provider did not effectively record, handle and respond to complaints.
Must-do action 12 of 13
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.
Must-do action 13 of 13
Must do
Well-led
The provider had failed to notify the Commission without delay of all significant events in line with their legal obligations.