Ashley Phoenix Home

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 inspection we rated this key question requires improvement. At this inspection the rating has remained requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to people’s safe care and treatment.

This service scored 50 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice had not been fully embedded into the service. For example, we found one incident in relation to a medicine error had not been recorded on the service incident reporting system.

One relative said, “I have been told about some of the incidents but some of them, not the others. Some are recorded, some are not. It’s intermittent and not consistent. They have made me aware by phone, but not all of them.”

However, the provider had recognised there had been an issue with recording and reporting incidents and had taken action to address this shortfall with the team. Leaders gave examples of how staff were now proactively involved with debriefing following an incident. They told us they were getting better at completing the information on the provider’s electronic incident recording system. The provider said staff had been supported to use the electronic incident recording system by the organisation. At the time of the inspection, it was too early to assess whether these changes had been fully embedded into practice.

We saw recorded incidents and lessons learnt were discussed in team meetings. Staff were offered opportunities to identify how improvements could be made. For example, purchasing safer sensory toys (toys used by people to help support their mental and emotional health) to reduce the risk of injury to a person. Staff told us they use the system to record incidents and are debriefed after an incident. One staff said, “We talk about best practice, and how it happened and better ways of doing things.”

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.For example, systems were in place to record and monitor people’s health needs; however, we saw a health log had not been updated to reflect the changes to a person’s health which had not been updated. This meant the person’s needs were not consistently recorded or monitored which could impact the quality and safety of their care. Leaders told us they were introducing new responsibilities and expectations with staff who had not been familiar with updating care planning documents.

Another example we found was a hospital passport that had not been updated to reflect their current speech and language therapy (SALT) eating and drinking guidelines. This posed a risk of the person receiving unsafe support during mealtimes during a hospital admission.

However, leaders informed us they organised care and support with people, together with health care partners and relatives to ensure continuity in care. Leaders and staff confirmed people were supported with all health appointments and would receive support from staff in the event of an emergency hospital stay and we saw records of health appointments were made following health care appointments.

The provider did not always work well with people and some healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from, avoidable harm and neglect.

We found the provider had not routinely shared safeguarding incidents with CQC and the local authority. However, the provider had recognised this issue and taken action. At the time of the inspection, safeguarding concerns were being appropriately reported to both the local authority and CQC.

Most relatives felt their relative was safe in the service and they had been informed of safeguarding incidents, one relative said, “Oh my gosh she is so safe there and I never want her to move from there. Another relative said they had called in the service unannounced, the relative said, “She was so clean and tidy and smiling away, ….” However, one relative expressed a dissatisfaction about how their relative had been safeguarded in the service.

However, the service had an up-to- date safeguarding policy and staff had completed safeguarding training. Staff we spoke with confirmed their awareness of the signs of abuse and how they would safeguard people. One staff member told us. “I am comfortable in raising concerns [about people’s safety], I will bring it up with management or go to managers above or whistle blow.” Leaders said they were confident about staff understanding of safeguarding and the processes around this. Leaders said, “staff are recognising safeguarding concerns and raising more concerns, staff tell us straight away about any concerns they have.”

Leaders confirmed there was a process to monitor the service for closed cultures, and they ensured staff were aware of the indicators of closed cultures through team meetings and direct conversations with staff.

We observed people appeared relaxed and comfortable with staff support and moving around the service.The provider had oversight of Deprivation of Liberty Safeguards (DoLS) authorisations and used a DoLS tracker to help them with their legal obligations in reapplying for DoLS authorisation in a timely way.

The provider did not always work well with people to understand and manage risks. Care planning documents were not always accurate and did not contain up-to-date information that reflected the current care and support needs of people who live in the service. For example, one care plan we reviewed had not been updated to reflect the mobility needs of a person where their support needs had changed. The provider had not assessed the risks in relation to a potential pressure wound for a person. However, the provider had sought advice from health professionals when the wound was identified and completed a risk assessment during the inspection. This was addressed by the provider at the time of the inspection and evidence was provided to CQC for assurance.

However, leaders told us they involve families in managing risk. Leaders said, ‘we rely on families for care planning information. We saw care planning information for people included details of how people communicated they were becoming anxious and distressed and how to support people to prevent them from becoming distressed. We saw risks were considered for a range of hazards, including falls, scalding and choking and measures had been put in place to reduce risks for people. Staff we spoke with appeared knowledgeable about people’s needs and how to support people around risks.

The provider did not always detect and control potential risks in the care environment. There were multiple trip risks in the garden. For example, an uneven step and overgrown weeds which could pose as trip hazards to blind people. Additionally, the Control of Substances Hazardous to Health (COSHH) cupboard and a room which was being redecorated was not secure which put people at risk of harm. This was addressed by the provider at the time of the inspection. However, these environmental risks were not related to emergency preparedness. The service had up-to-date personal emergency evacuation plans (PEEPs) for all people living at the care home and routine fire safety checks took place. The environment had adaptations and reasonable adjustments in place to help meet people’s individual needs. For example, staff ensured people were familiarised with any changes to the environment and made efforts to ensure household items were always in the same place to minimise trip risks inside the service.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staff received specific training to ensure they met the needs of autistic people and people with a learning disability. Staff had received training in mandatory courses to enable them to support people safely. Leaders confirmed staff received specific training to support staff to communicate with people who are Blinddeaf. We observed staff signing with people, using people’s preferred communication styles.Recruitment files had all appropriate processes and checks in place. There was an effective system to ensure oversight of staffing document renewals and ensure supervisions were held regularly. Supervision records demonstrated staff were provided with opportunities to talk about their role, identify training needs and hear feedback about their work performance.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. For example, the Jacuzzi bath had not been risk assessed, and a safe system of work had not been put in place to reduce the risk of legionella. This placed people at risk of ill health. However, the service routinely made hot water checks to reduce the risk of legionella and a general legionella risk assessment for the service was in place. Records showed the service was cleaned regularly. However, we saw some areas of the home appeared unclean and there was a build-up of crumbs on the kitchen floor in the corners. This placed people at risk of attracting pests and ill health.

We saw some gaps in the provider’s daily food safety checks. However, this had been identified through a management audit and daily food safety checks were now being monitored by management and there appeared to be an improvement in records.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Controlled drugs were not being managed correctly in the service and there were no facilities to appropriately dispose of used topical controlled drugs patches. Documentation relating to the management of topical patches was not always being completed by staff. Staff did not act and seek clinical advice when a resident removed their topical pain relief patch before the prescribed interval. This placed the person at risk of not receiving effective pain relief. The management team took action to ensure the person's pain relief was reviewed by the GP during the inspection. Medicines requiring refrigeration were not appropriately stored in the home and effective temperature monitoring was not taking place for the fridge. This meant we could not be assured that medicines stored in the fridge were suitable to be used. The management team took action during the inspection and installed a medicines fridge.

Some people’s care plans did not always reflect their individual needs. For example, there were not always adequate details included on how some people liked to take their medicines, particularly those that were not taken orally. Additionally, for some people not all medicines were listed in the care plan. This posed a risk of people not receiving their medicines safely or in their preferred way. Risk assessments related to prescribed topical flammable emollient creams were missing for some people. Some medicines, such as pain killers, were prescribed to be used “PRN” or “when required”. Protocols were not always in place to support staff to make decisions about when these medicines would be required by people. There was a process for reporting medicines incidents and errors established in the home. However, during our inspection we saw examples of medicines incidents that were not recorded. The meant that opportunities for learning and improving were missed.

There was a medicine policy available. However, the provider could not be assured that staff always followed it. For example, although monthly medicines audits were being undertaken these had failed to identify the issues we saw with medicines during this inspection. At the time of the inspection leaders took action to ensure appropriate documentation was available and began to make improvements to monitor medicines fridge temperatures.