The Care Quality Commission (CQC) has dropped the rating for Ashcroft House – Leeds from requires improvement to inadequate following an inspection in January and February.
The home, run by Ashcroft House Care Services Limited, provides personal care for up to 32 older people.
This inspection was prompted in part by two incidents, one in which a person in the service died, and another in which a person was seriously injured. CQC are currently investigating these incidents to decide whether further regulatory action needs to be taken and will report on this when able to do so. The information shared with CQC about the incidents indicated concerns around the management of choking risks and environmental risks, which were examined during this inspection and the findings are in this report.
As well as the home’s rating dropping from requires improvement to inadequate overall, so have the ratings for how safe, effective, and well-led the service is. The home’s rating for caring has dropped from good to inadequate. Its rating for responsive has dropped from good to requires improvement.
The service is now in special measures which means it will be kept under close review by CQC. CQC have also taken further enforcement action to protect people and will report on this when legally able to do so.
Sheila Grant, CQC deputy director of operations in the north, said:
“When we inspected Ashcroft House we were deeply concerned to find people’s care wasn’t always tailored to meet their individual needs or manage serious risks to their safety. The service also wasn’t learning lessons when things went wrong.
“We found that even after somebody had died after choking, leaders hadn’t arranged for people at risk of choking to have their care plans reviewed and updated. They only did this after our inspectors told them to do so.
“People were living in an environment that was poorly maintained and dangerous. For example, the home had left scalding radiators uncovered despite us warning them about this in the past, and hadn’t properly secured wardrobes to people’s walls even after someone was injured by one falling.
“We saw staff didn’t always seek out people’s preferences or consent for their care, which risks violating their human rights. And while we saw some individual staff were caring, people told us staff didn’t always treat them kindly or respect their privacy.
“We’ve told leaders at Ashcroft House to take urgent action on the issues we found and we'll be monitoring this service closely to ensure people are kept safe in future. We’ve also taken further enforcement action and will report on this when we’re legally able to do so.”
Inspectors also found:
- People’s medications weren’t always managed safely, and some people hadn’t received their medications for multiple consecutive days
- People told inspectors there weren’t enough staff to support them when needed, or to meet their social and emotional needs. Inspectors saw staff didn’t have time to engage with people and there weren’t many activities available that people could do independently. People hadn’t been offered a trip out of the home since September 2023
- The home’s environment wasn’t designed to meet the needs of people with dementia. For example, people’s bedroom doors weren’t clearly identifiable to help people find their room
- The service wasn’t always monitoring how much people ate or drank, or acting on concerns about people’s nutrition.