Ashurst

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has remained as good. This meant people were safe and protected from avoidable harm.

This service scored 78 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. The provider learned lessons from incidents to continually identify and embed good practice.

The provider had clear records of all accidents and incidents which had occurred at the service. They focused on identifying the root cause of incidents and shared any new information with other professionals to gain a better understanding of the person.

The manager and deputy manager had oversight of all accidents and incidents and reviewed them consistently. The quality report from April 2025 showed leaders had reviewed 100% of incidents between April 2024 and March 2025. Most incidents which we reviewed had positive comments from the manager and the deputy manager regarding how staff had responded to the concern.

Staff had a good understanding of how to report accidents and incidents. A staff member said, “We are encouraged to raise any concerns,” and “After each incident we will put in an incident report; we get feedback from the manager and learn about other incidents through discussions, emails and in handovers.”

The provider ensured learning from every incident. There was evidence of leaders and senior staff completing debriefs with the people and staff following incidents occurring.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. The provider had an equal opportunities admissions policy which ensured no person would be refused admission based on protected characteristics including race, ethnicity, skin colour and faith. They made sure there was continuity of care, including when people moved between different services.

The provider safely managed people’s transitions between care services. The referrals coordinator and clinical pathways manager completed a referral screening tool ensure the person’s needs could be met by the provider. Bed allocation and impact risk assessment meetings were held to decide on which location, owned by the provider, would be best suited for the person. The provider met with the person and completed a ‘person’s transition support form’ which supported the person to be involved in discussions around their care pathway and transition. Detailed transition timelines were in place for people when they were moving into the service which were graded and individually tailored.

Professionals, such as the clinical nurse specialist and psychologist prepared and completed presentations for staff about new people entering the service. The information was detailed and included the person’s background, presenting concerns and advised staff on how best to support them.

A relative told us they were impressed by how the transition to the placement was managed, they said, “My relative went and had a day visit and then an overnight visit before moving in.”

The provider managed transitions and referrals out of the service well. The provider shared information or escalated concerns to external services and appropriate bodies well. The provider evidenced reflections and learning from admissions which had ended prematurely.

The provider ensured professionals such as hospital staff had all the relevant information about a person when they were transferred to them.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

The provider supported people with a range of emotional or behavioural needs, including those who were at times vulnerable to self-harm or experiencing suicidal thoughts. The provider worked with people to help support them to feel safe. Staff were trained in ‘Safewards for Safehomes;’ Safewards is an evidence-based model that is designed to reduce conflict and containment and is achieved through ten key interventions which include establishing and agreeing on shared expectations, encouraging staff to use calm and de-escalating language, supporting people when they receive distressing news and promoting mutual understanding through structured activities.

The provider completed ongoing assessments to monitor people’s risk of harm and consistently updated care plans and formulations. They involved external professionals and the person themselves in discussions about their safety. We saw evidence all safeguarding incidents were thoroughly investigated in an open and transparent way.

Safeguarding policies and procedures were aligned to the latest and best practice and included details of local authorities for staff to contact when required.

The provider ensured staff and leaders were trained to recognise and report abuse and challenge discrimination. Leaders had completed level 4 safeguarding training for adults and children, whilst staff members had completed level 3 safeguarding training.

The provider ensured safeguarding notifications were submitted to external bodies such as the CQC without delay.

Staff said if they had any safeguarding concerns, they would discuss with senior staff on duty in line with the provider’s policy.

People appeared relaxed and comfortable with staff.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided safe care to meet people’s needs, which was supportive and enabled people to do the things that mattered to them.

The provider adopted ‘therapeutic risk management’ and ‘least restrictive practices’ as core principles of care. Therapeutic risk management allowed people’s risks to be openly discussed; for them to be active participants in understanding and managing their risks and for professionals to tailor interventions to the level of risk for the person, meaning overly restrictive or reactive responses to risk were avoided. The provider worked on the principle that conflicts and incidents could be avoided with the right interventions such as de-escalation.

The provider aimed to identify and understand the root cause of the person’s emotional or behavioural needs and worked alongside specialists to understand how best to safely respond to these. People had person centred risk management plans in place. They were developed in collaboration with the person and included distraction techniques and communication strategies to support them to convey their distress and access appropriate support.

People were allocated a clinical nurse specialist who visited at least weekly, had access to inidividual psychological therapy which was based on individual needs and saw a psychiatrist once a month for medical review. The Multi-Disciplinary team directed care planning and risk management to support people's recovery.

The provider shared key information about people at the MDT meetings which were attended by a variety of experts and professionals, including the person’s psychologist, psychiatrist and clinical nurse specialist.

The clinical nurse specialist, a member of staff, whether that be a senior or a manager, and the person were invited to attend a core group session monthly. The session had various functions including to review the progress made, discuss any complications, agree on goals and review medication. Records showed on occasions people did not attend these sessions, however the sessions continued regardless, and the clinical nurse specialist emailed the person or spoke with them to remind them of the importance of attending.

Staff completed risk assessments for each person on arrival, and reviewed these regularly, including after any incidents. We reviewed the records for both people and found they had comprehensive risk assessment and risk management plans in place.

The care plans and risk assessments supported people to have as much freedom, choice and control as possible. People had access to their care plans, and we saw these were person centred and had clear goals and aspirations for the future.

Leaders updated staff in a timely manner when updates to risk assessments were made. Staff told us they would be emailed or receive this information via handover meetings or through general discussions with other staff.

Staff were aware of the risks affecting each person and what actions they needed to take to minimise the risk of harm. Staff had an extensive knowledge of the potential triggers which may cause risk to increase for a person, and what strategies they would follow. They told us how they reviewed care plans and risk assessments regularly, how the clinical nurse specialist updated them on new strategies and how their training had equipped them to carry out their duties effectively.

A leader told us how they felt comfortable leaving the home at the end of their shift as they had full confidence in the staff being able to manage people’s heightened distress and potential risk.

The provider ensured residential staff had access to 24/7 support from the clinical team to manage crises effectively and avert any unnecessary admissions by liaising closely with accident and emergency departments and crisis teams.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

People were cared for in a safe environment which had been designed to meet their needs. The service was small scale, community based and individualised. The environment was adapted to meet sensory needs. The downstairs of the home had ample space for staff and people to move around, and the kitchen was open plan which encouraged meals being cooked collaboratively. There was a large, secure, enclosed and well landscaped garden area which was used regularly by the people.

In March 2025, the service made the decision to improve environmental sustainability by switching cleaning products and introduced waste recycling by staff and people.

The provider had considered how the environment needed to keep people safe from psychological harm, as well as physical harm. The provider evidenced a ligature risk assessment which was highly detailed and considered the specific risks associated with the person, the risks associated with the location of the ligature point and the risks associated with the ligature point itself (including the weight of the bearing). Multiple factors led to an individual risk assessment score for each ligature point.

The provider ensured facilities and equipment were well maintained. The provider evidenced how appropriate checks had been completed; for example, portable appliance testing was up to date and equipment had been serviced as required. Regular fire safety checks and fire drills had been completed, and an external fire risk assessment had been completed in December 2024. The initial health and safety building inspection audit from 2021 had been revisited and it was clear remedial actions had been taken to resolve areas which needed improvement. The provider ensured weekly health and safety checks and a daily walkaround were completed which identified any concerns with the environment or equipment.

People who required a personal emergency evacuation plan had them in place.

Staff we spoke with, a person who used the service and a relative did not raise concerns regarding the environment within the home. A staff member told us, “There is the odd thing which may not be working but when we tell management, or when they pick it up, they act quickly to resolve it.”

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. The provider employed consultant psychiatrists, clinical psychologists and clinical nurse specialists who supported the residential care team which included the leads, senior mental health support workers and mental health support workers. They worked well together providing safe care that met people’s individual needs.

The provider always ensured safe staffing levels which were based on the needs of the people, as set out in their care plans. Rotas were completed well in advance for staff and the provider had contingency plans in place if staffing levels dropped below the numbers required. Leaders, staff, a person using the service and a relative told us there were enough staff to support the needs of the people living at the care home.

Leaders used values – based recruitment processes to safely recruit staff, with all necessary checks and documentation in place. Application forms were fully completed, and at least 2 references were obtained prior to a new recruit starting work. Interview questions and answers forms were kept. UK disclosure and barring service (DBS) checks were completed to ensure staff were of suitable character to work with vulnerable adults.

The provider kept detailed records of staff training and had good oversight of what courses, qualifications, and other learning had been undertaken.

Staff confirmed they had undertaken mandatory training and were up to date with this. The scope was wide ranging, for example, staff had training in various areas including clinical training, model of care, health and safety, physical health and medication training. Under those areas, staff had completed modules which included basic life support, autism and learning disability and understanding diagnosis and distress. Training compliance was high. Staff told us they felt well trained and competent in their roles.

All clinical and residential staff who started with the service received a 6-day induction package which focused on providing a detailed understanding of the provider’s model of care. The training was relevant and appropriate for the roles recruited to and included modules such as ‘wound care’, ‘the therapeutic risk management model’ and ‘boundaries and assertive care.’ A newly recruited staff member told us how their induction had been comprehensive. Staff had a probation period of at least 3 months to ensure they were capable to complete the role.

The provider evidenced training, support and supervisions were being completed by management and staff on a regular basis. This allowed staff an opportunity to discuss their support needs and learning.

The provider supported succession planning that provided opportunities for internal talent to develop into more senior roles and potentially future managers. The registered manager and deputy manager were examples of this.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The provider had clear policies and procedures in relation to infection, prevention and control (IPC). The manager completed daily and weekly walk arounds for the service which reviewed the cleanliness of the home.

There was an effective approach to assessing and managing the risk of infection, which was in line with current relevant national guidance. People were protected as much as possible from the risk of infection because the premises and equipment were kept clean and hygienic, and there were no offensive odours. The night staff tended to clean throughout the home during their shift, although staff and leaders told us it was everybody’s responsibility to clean and tidy. Sharps and clinical waste bins were present and managed by an external provider.

Leaders and staff proactively promoted cleanliness and involved the people who were supported in cleaning and tidying the home to ensure good infection control and hygiene.

Staff used appropriate cleaning products which were stored safely in a cupboard, and waste materials were disposed of properly. Enough staff were employed to keep the premises clean. Staff told us they did not have concerns regarding IPC within the home and had sufficient training.

A person and a relative we spoke with told us they did not have concerns regarding IPC.

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Staff stored medicines safely and securely. Staff ensured the dedicated area for medicine storage was locked and key codes were in place. Drug keys were safely managed. Oxygen was stored in a cylinder in the locked area. Staff ensured fridge temperatures were appropriate, and these were recorded.

The controlled drugs area complied with regulations. Staff ensured the controlled drugs book was in good order with stock counts which were accurate and clearly signed and dated 3 times a day. Controlled drugs were recorded on the electronic medicine administration record (eMAR) as well as the running total on the controlled drug register.

The provider evidenced accurate recordings on the eMAR. Charts had photo identification, known allergies and GP details.

The psychiatrist reviewed ‘prescribed when required’ (PRN) medications. There was 1 controlled drug located in a secure area at the time of the inspection.

Staff checked all ordered prescriptions and medications which needed to be disposed of were stored in a locked tamper proof container.

People’s medicines were clearly labelled and legible. All creams and drops were individually labelled, and we saw the use of body maps.

The provider had regular local authority medication audits as part of their quality monitoring support which were documented. In addition, monthly internal eMAR audits were completed by leaders.

The provider safely stored supplement drinks in a fridge in a locked room with evidence of temperature monitoring in place, these were clearly marked and in date.

The provider safely stored emergency equipment. An emergency grab bag was in place which included a defibrillator and other necessary equipment in the event of an emergency.

Staff did not have access to drug disposal kits; however, this was acceptable as there were only 2 people in the accommodation at the time of this inspection and we did not identify over stocking or out of date medication.

Staff had access from a clinical nurse specialist, which included out of hours support. The on-call personnel were clearly displayed in the office and both people had a named psychiatrist and GP.