Ashcroft House: Leeds care home placed under special measures by CQC after resident dies from choking

The Care Quality Commission (CQC) has dropped the rating for Ashcroft House on Leeds Road in Bramhope from requires improvement to inadequate following an inspection in January and February.  

This inspection was prompted in part by two incidents, one in which a person in the service died from choking, and another in which a person was seriously injured. CQC are currently investigating these incidents to decide whether further action needs to be taken.

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. 

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."

She said that the environment was "poorly maintained and dangerous", adding: "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 that medications weren't managed safely, with some people not receiving their medication for days, and that there was not enough staff to support residents.

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Concerns were also raised about the environment created for people with dementia and also the residents' nutrition.

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. 

The report will be published on CQC’s website on Thursday 21 March.