Archived: Ashingdon Hall

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

At our last inspection to the service in December 2023, not all risks to people's safety and wellbeing were identified and recorded. The provider’s processes and procedures to protect people from abuse was not robust. Suitable arrangements were not in place to safeguard people’s financial arrangements. People were not protected by the prevention and control of infection. Staff were not adequately trained to deliver effective care and support and had not received an induction, regular supervision, or an appraisal. This was a breach of Regulation 12 [Safe care and treatment], Regulation 13 [Safeguarding] and Regulation 18 [Staffing] of the Health and Social Care Act 2008 [Regulated Activities] Regulations 2014. Enough improvement had been made at this assessment and the provider no longer remained in breach of Regulation 13. However, not enough improvement had been made at this inspection and the provider remained in continued breach of Regulations 12 and 18.

Risks to people were not safely monitored and managed to support them to stay safe. Risks to people’s safety and wellbeing were not routinely identified or provided enough detail as to how known risks presented should be mitigated. The physical environment of the residential suite would not currently meet people’s needs or be fit for purpose and improvements were required. Not all staff had the skills, knowledge, and experience to deliver effective care and support. Not all staff had received an induction, regular supervision, or an appraisal of their overall performance. Recruitment practices were not safe as relevant checks were not carried out before a new member of staff started working at the service.

Staffing levels were appropriate to meet people’s needs. People received their medicines as prescribed. People were protected by the prevention and control of infection.

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.

Accident and incidents were recorded. However, there was no evidence to demonstrate information relating to these were shared with staff to improve safety and lessons learned. Therefore, we could not be confident fundamental information was shared to prevent accidents or incidents reoccurring.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People told us they felt safe. A relative told us they had no concerns about their family member’s safety. They stated, “My X is definitely safe here.”

Staff were able to tell us about the different types of abuse and what to do to make sure people were protected from harm. A member of staff told us they would escalate any concerns to the manager. The manager was aware of their responsibility to notify CQC and the local authority of any allegations or incidents of abuse. Most staff had completed up to date safeguarding training.

At our last inspection to Ashingdon Hall in December 2023, appropriate systems and processes were not in place to safeguard people’s finances. At this assessment we found the procedures and processes relating to the financial management of people’s monies had significantly improved. Transactions and monetary balances were now accurately recorded, and receipts were evident to demonstrate people’s expenditure.

A relative told us, “They involve me with everything including any risks. Staff liaise with me about everything.”

The staff we spoke with clearly knew people well. However, staff practice as described in observations meant we were not assured they were always following the guidance that was recorded within care plans.

Risks to people were not safely monitored and managed to support them to stay safe. We observed 6 separate incidents during our assessment whereby staff, including a senior member of staff, performed unsafe moving and handling practices. This referred to staff putting a person using the service at potential risk of harm by placing their hands under the person’s underarms when assisting them with transfers from their comfortable chair to a standing position using their walking frame and into a wheelchair and vice versa. This practice is unsafe and can cause the person to experience discomfort and injury. This was despite the person being observed to independently transfer using their walking frame when they were given

A person was identified as having poor skin integrity. They required a pressure relieving cushion to be in place whilst sitting to reduce the risk of pressure ulcers developing. Observations during both days of our assessment evidenced the person did not sit on the cushion used to alleviate the risk of potential pain, discomfort and pressure ulcers developing that comes from long periods of sitting down.

Not all risks to people’s safety and wellbeing were identified or provided enough detail as to how recognised risks should be mitigated. This referred specifically where people could become anxious, distressed and exhibited behaviours that could place themselves and others at risk of harm. This put people at potential risk of not having risks to their safety met in an appropriate, consistent and safe way.

Where people were judged to be at risk of dehydration and required their fluid intake to be monitored and recorded, records demonstrated their fluid targets were not always maintained and there was a lack of evidence to show what was being done to monitor and address this. A person’s care plan referred to them requiring their body to be repositioned at regular intervals to reduce the risk of pressure ulcers developing. However, records showed these were not routinely completed. This meant we could not be assured the person was being repositioned in line with their care needs to reduce the risk of their skin integrity declining.

Effective arrangements were not in place to mitigate risks for people using the service and to keep people safe. This demonstrated a continued breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Staff told us they felt the environment on the dementia suite was well maintained and that they had access to the equipment they needed to support people safely.

The provider employed a maintenance person for the day-to-day upkeep of the service. The environment [dementia suite] was well maintained, and staff had access to the equipment they needed to support people safely. There were systems in place to ensure maintenance required was highlighted by staff for action and responded to promptly by the person responsible for maintenance. Appropriate fire detection, warning systems and firefighting equipment were in place and checked to ensure they remained effective.

At the time of our assessment although no one was living within the residential suite we looked at the premises and found that if CQC gave the provider permission to admit new people to the service, the physical environment would be unsafe and not fit for purpose. The main communal lounge was being used to store boxes and black bags containing archived documents from both Ashingdon Hall and the provider’s other services. Personal items belonging to previous occupants remained in some bedrooms. The environment was tired and worn, with areas requiring redecoration, there were damp patches noted within at least 2 bedrooms and the veneer to some beds [headboard and footboard] were worn or peeling. This was not considered and included for action within the service’s Service Improvement Plan.

No concerns were raised by people using the service or their relatives about staffing levels and the deployment of staff. A relative told us, “There is absolutely enough staff at the moment, they [staff] are very attentive.”

Staff told us there were always sufficient staff on duty to meet people’s needs. The manager confirmed people’s dependency needs were assessed. However, it was not clear as to how this information was being used to inform existing staffing levels. The manager told us they did not understand the process either.

Staffing levels as told to us by the manager were maintained during both days of our assessment. We found staff were visible and available to meet people’s needs promptly. Observations demonstrated the communal lounge within the Dementia Suite was supported by staff at all times. There were sufficient staff available to facilitate social activities for people throughout the day.

Recruitment practices were not safe as relevant checks were not carried out before a new member of staff started working at the service. No reason for leaving previous employment or right to work in the United Kingdom had been explored. Not all written references were obtained prior to staff commencing in post. Staff had not received a robust induction. Disclosure and Barring Service [DBS] and 'Adult First' checks were not routinely completed. DBS checks provide information about convictions and cautions held on the Police National Computer.

The provider did not ensure all required recruitment checks were completed. This was a breach of Regulation 19 [Fit and proper persons employed] of the Health and Social Care Act 2008 [Regulated Activities] Regulations 2014.

The service did not ensure staff had the skills, knowledge, and experience to deliver effective care. Although a new eLearning platform had been sourced, it was difficult to determine the overall level of compliance with training as not all staff training records could be located and the matrix provided was not up to date. Observations of staff’s practice did not provide assurance staff were skilled and competent to effectively apply their learning in their everyday practice. For example, although staff had received ‘practical’ moving and handling training in 2023, not all staff’s practice was effective or safe.

Since December 2023, 3 members of staff had been promoted to a senior position. There was no evidence of them having received a revised job description or having been provided and completed an induction to this role. Staff had still not received regular formal supervision or an annual appraisal, and this included the manager.

The provider did not ensure staff had the competence and skills for their role or received an induction or supervision. This was a continued breach of Regulation 18 [Staffing] of the Health and Social Care Act 2008 [Regulated Activities] Regulations 2014.

Staff we spoke to told us there was sufficient personal protective equipment [PPE] available. Not all staff had up to date infection, prevention and control training.

People were protected from the risk of infection because the premises [Dementia Suite] and equipment were kept clean and odour free. Staff were observed using PPE appropriately and when required.

Audits relating to the service’s infection, prevention and control arrangements were being conducted and demonstrated there was a good level of compliance. Most staff had received appropriate infection, prevention and control training.

Staff confirmed they had completed medicines training and had their competency assessed on an annual basis to ensure their practice remained safe. The manager had completed medicines competency checks for 3 senior members of staff, despite their last competency check for medicines being completed in October 2020. We could not be assured they remained competent to give medication safely and to check the competency of other staff.

People were supported to receive their medicines as prescribed. We looked at the Medication Administration Records [MAR] for each person living at the service. These showed each person received their medicines at the times they needed them, and records were kept in good order. The medicine rounds were evenly spaced out throughout the day to ensure people did not receive their medicines too close together or too late. Observation of staff practice showed staff undertook this task with dignity and respect for the people being supported. However, there were no protocols in place for PRN [“as needed”] medicines, despite this having been identified at our previous inspection in December 2023. This meant there remained no guidance for staff on when and how to administer PRN medicines to people using the service.