Ashridge Court Care Centre

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 changed to Requires Improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

This service scored 59 (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.

Staff reviewed accidents and incidents, and there was some evidence of actions taken and lessons learned from these. However, preventative measures and actions were not always recorded. For example, there had been medicine errors which whilst acknowledged by the service, they had not demonstrated any actions taken or retraining. This was regarding medicine administration and the provider was to further investigate to ensure learning was taken forward.

We saw evidence of some learning from other incidents, such as discussions in team meetings with staff. During the inspection process, leaders were open and responsive to feedback which demonstrated their commitment to learning.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Care plans showed clear assessments when people moved to Ashridge Court Care Centre. Partners told us they worked collaboratively to support transfers between services for example, hospitals and clinics.

There were concerns raised by staff regarding late arrivals from hospital which put pressure on staff working and safe outcomes. The provider told us that a contingency plan for late admissions would be put into place to avoid potential issues. For example, extra staff being available on arrivals days to ensure safe transitions into the service.

The provider did not always work well with people and 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 bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately. Information gathered from health professionals, social care and from families indicated that not all incidents and events had been reported to the relevant authorities. For example, recurrent falls and skin damage. Retrospective forms were now being completed. Staff understood different types of abuse, safeguarding procedures and described how they would deal with concerns. Staff members explained, “I would go to a nurse or a member of the management team with any concerns and would use the whistleblowing policy if I needed to” and “We would raise any thing we thought was abuse, wouldn’t hesitate.” However, despite staff having concerns about unsafe staffing levels they had not raised it as a safeguarding. They had not thought unsafe staffing levels would be a safeguarding even though they told us that current staffing levels placed people at risk of neglect. This was discussed with leaders, and they immediately met with staff and increased staffing. They stated they would provide further training and support for staff to encourage them to raise concerns. When people were asked if they felt safe in the home they replied, “Yes. Kind staff but they are rushed, bless them.” The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS) The service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty. Best interest meetings were held to ensure the restriction was in their best interest and all other options discussed. Deprivations of Liberty Safeguards authorisations (DOLS) had been made when needed, for example, covert medicines and bed rails. The Registered manager had put a monitoring system in place to ensure they were kept updated as required. There were some discrepancies which the management team were to look into, to ensure that all restrictive practices such as covert administration of medicines were reflected clearly.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Each person had individual computerised care plans and risk assessments. Care plans and related risk assessments were not all person-centred or reflective of people’s current individual needs. Some care plans contained little guidance for staff to follow to provide consistent care delivery to ensure peoples’ health and safety. These were discussed and immediate action taken and therefore the risk was mitigated. There were concerns identified regarding the records of peoples’ weights and the lack of oversight from senior staff. There was evidence of recent unaccounted for weight loss which had not been identified, followed up or actions taken to prevent further weight loss. This was fully discussed and the provider told us that these would all be checked and appropriate action taken if necessary. Risk assessments whilst updated monthly did not always reflect changes to people’s health and mental well-being. Examples were discussed during the inspection and would be reviewed against peoples care plans to ensure continuous safe care. Another person’s care plan stated they required repositioning every 2-4 hours, however care records and our own observations, demonstrated this person was being repositioned less frequently, for example, their positioning was not changed in 6 hours and this impacted on their comfort. We brought this to the attention of the management and immediate action was taken. People and visitors had no concerns and told us, “Very safe, they are very good,” “I have no concerns regarding my relative’s safety,” and “I trust staff and feel safe.” There were people who lived with diabetes, and we saw that staff monitored their health, lifestyle choices and liaised with health professionals as necessary. People at risk of choking had been assessed and referred as necessary to the GP and Speech and Language therapists (SaLT). Risk had been mitigated by ensuring people had appropriate modified food and drinks and that all staff were had had training. Emergency equipment to deal with choking was ready for use and regularly checked. Wound care documentation was in place for those with wounds, which included photographs and details of treatment in line with good practice guidance with evidence of wound improvement. The management team undertook an analysis of incidents and accidents and referrals were made for additional support where required, for example, in reach team, falls team, and GP involvement. Staff received training in areas of potential risk such as moving and handling, first aid and health and safety. All staff received fire training and undertook night and day evacuations to ensure all staff have confidence in the event of fire to manage people safely. Personal Emergency Evacuation Plans (PEEPS) had been completed for each person. PEEPS give staff or the emergency services detailed instructions about the level of support a person would require in an emergency such as a fire evacuation.

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

The provider was fully aware of all potential risks in the care environment and mitigated them well. They made sure equipment, facilities and technology supported the delivery of safe care. The environment was a mix of an older building, whilst an extension had been purpose built and specifically designed with bespoke features to mitigate risk, such as level flooring to all areas where people had access to. The provider had considered the specific needs of people living with dementia when designing the environment and people had easy access to both internal and external spaces which were safe and promoted independence.

The environment was safe and well cared for. Care equipment we saw was in good working order and documentation to support regular servicing was seen. It was identified that communal bathrooms were used to store equipment and during the first site visit these were cleared and stored into a spare bedroom.

Processes ensured the environment was safe and well kept. Health and safety checks had been undertaken to ensure safe management of utilities, food hygiene, hazardous substances, moving and handling equipment, staff safety and welfare. There was a business continuity plan which instructed staff on what to do in the event of the service not being able to function normally, such as a loss of power or evacuation of the property. There were detailed fire risk assessments, which covered all areas in the home. Premises risk assessments and health and safety assessments were reviewed on an annual basis, which included gas, electrical safety, legionella and fire equipment. There had been a recent fire inspection which had identified work to be undertaken by the 22 October 2026, and this had been undertaken.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Feedback from staff, people and families was consistent in that they said, “Not enough staff, staff are lovely but rushed, stretched to the limit I would say,” “It’s so busy we can’t do our job like we want to, we need more staff” and “It’s been crazy busy, just can’t do it all.” A relative said, “It’s noticeable lately the staff are great but bells ring for ages and sometimes I don’t see a member of staff.”

From our observations on the first site visit it was evident that there were not enough staff deployed, call bells went unanswered for up to ten minutes and a visiting health professional had been searching for staff assistance for 15 minutes. There were continuous long call bell calls throughout the morning until staff had finished the morning medications and people’s personal care. There were a large amount of people left in bed without a clear rationale. When asked why so many people were in bed, staff told us, “It is because we don’t have the time to get people up, which is not right but we prioritise.” Families also were worried that staff didn’t have time to get their loved one up and walking. We shared our concerns immediately with the senior managers, who immediately authorised one more staff to work, beginning the next day. We were also informed by a regional manager that they had identified a few weeks earlier that more staff were needed and authorised this with the registered manager, but it had not happened. We were provided with new rotas for the next month which showed that the shifts were to be covered by agency and the homes own staff bank.

On the second and third site visits, the differences were noticeable, staff were happy, the atmosphere the floors were less chaotic, call bells answered with 4 minutes and 70% of people previously in bed were up and joining in activities and in the lounges. We were given assurances that staffing levels would be maintained and a dependency analysis completed by the deputy manager. The team acknowledged that there had been new people coming into the home, some people becoming poorly and staffing levels had not been considered.

The provider had not ensured that staff had received effective support, supervision and development. Staff said, “We do get training both online and face to face, and nurses are always happy to show us things” and “We do training online but I have not had supervision regularly.” The supervision matrix evidenced that staff were not receiving regular supervision. This was acknowledged by the provider, it is thought that there had been group supervisions, but these had not been recorded.

Staff were recruited safely. The provider undertook checks on new staff before they started work. This included checking their identity, their eligibility to work in the UK, obtaining at least two references from previous employers and Disclosure and Barring Service (DBS) checks. The DBS helps employers make safer recruitment decisions and prevent unsuitable people from working with vulnerable people. Registered nurses have a unique registration code called a PIN. This tells the provider that they are fit to practice as nurses. Before employment, checks were made to ensure the PIN was current with no restrictions.

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. There were areas of the home that were not clean, these included equipment in communal bathrooms, clinical rooms, cupboards/drawers and beakers. Action was taken immediately. The provider has introduced further walk arounds to ensure complete oversight. However, peoples' bedrooms and communal areas were clean. Visitors told us, "The housekeeping staff are really good, it's clean and smells nice" and "The housekeepers are always busy." Staff told us they are well resourced for cleaning and infection control. One said, "Personal protective equipment (PPE) is always available, we have enough and also cleaning products and equipment." People's rooms were cleaned regularly by housekeeping staff and visitors commented positively, with no-one reporting any problems with the standard of cleanliness of the environment and equipment. We visited one room with the person, who told us, "I love my view, it's a joy to live here." The room was clean, comfortable with the persons' personal effects displayed. People's laundry was managed well, and the laundry room was clean and well organised, and people were well dressed The housekeeping staff understood their role and followed appropriate procedures to keep the home clean. All staff understood their responsibility to reduce the risk of infection and followed infection control guidance. There were posters and training to assist staff in keeping up to date with any changes to infection control measures. Audits were completed to ensure compliance with the procedures and policies of the home. Staff were trained in the use of personal protective equipment (PPE) and of the importance of good hygiene practice.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Staff supported and involved people to manage their medicines and followed best practice for administering medicines. One person told us, “I am grateful that they do it all for me, it was getting too much for me at home, stress is gone.” Staff documented medicines clearly in care plans and made sure medicines accompanied the person between healthcare settings. Not everyone could share their experiences regarding medication, but one person said, “Staff do give me my medicine, they keep me informed of changes.” One family member said, “No worries at all, if there are changes or the GP stops them, staff will inform us.” The management of medicines were very well organised, with minimal extra stock and all medicines no longer required were managed safely and returned as per their pharmacy’s procedures. Staff who gave medicines had the relevant knowledge, training and competency that ensured medicines were handled safely. We observed staff giving medicines safely and that they were recorded accurately on the eMAR (eMAR, an electronic medical records software.) All discrepancies and medicine errors were recorded and investigated and action taken as required. Daily and twice daily for controlled medicines and monthly audits were carried out, and any shortfalls were addressed and used as ‘lessons learnt.’ Protocols for ‘as required’ (PRN) medicines such as pain relief medicines were in place, they were informative and person specific. Some people had been prescribed just in case medicines to be used at the end stage of their life.