Ashlands Care 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 assessment we rated this key question requires improvement. At this assessment 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 44 (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. Lessons were not always learnt to continually identify and embed good practice. We found that the service did not consistently demonstrate a strong learning culture. Staff engagement in reflective practice was limited, and we saw little evidence of structured or shared learning following incidents. While some learning took place reactively, it was not part of a structured approach to improvement. Staff told us that while some learning happened after issues arose, there was little evidence of structured reflection or shared learning across the team. Staff were happy with the competency checks they had with the manager and found them helpful. One staff member said, “I receive monthly competency checks with [manager], they are supportive and I like the feedback.”

Staff told us that although some improvements were being made, opportunities for team-wide reflection and learning were not consistently used. People using the service told us they felt able to raise concerns and speak with staff. One person said, “They [management] are approachable,” and another commented, “If you have a problem, they do listen to you.” However, we found that frequent changes in management had affected continuity and may have contributed to a lack of sustained learning and development. We found that the new manager had started to introduce new processes aimed at improving quality and oversight. The manager told us “We look at incidents and see where we can learn from it and stop it happening again.” However, many of these changes were still in the early stages and had not yet been embedded.

The provider did not always work well with people to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. We saw that care plans often contained incomplete or conflicting information. For example, some plans listed different types of slings for the same person, which could lead to unsafe care. We also observed a person being weighed in the main lounge, which compromised their privacy. There was limited evidence of clear documentation around dietary needs or medicines, which could affect safe transitions between services or shifts. We found there was no structured welcome process for new people meeting others when they came to the service. Some new arrivals were not introduced to others and were left sitting alone. One person said, “We couldn’t sit together as there were no spaces.”

However, the provider made sure there was continuity of care, including when people moved between different services. Staff were confident in identifying when someone was unwell and seek emergency care. One staff member said, “We are trained to see signs of deterioration and act quickly to ensure people are safe.” The provider ensured they were aware of people’s needs before accepting them into the service to ensure they could meet their needs. The manager told us. “We think about if we can meet that persons needs and how it would impact the other residents.”

The provider did not always concentrate on improving people’s lives or protecting their right to live in safety. There were no reports from people of abuse, but some people felt unsettled at times. Most people said they felt safe and relaxed. One person said, “Yes, I am actually—it feels like being in a big family.” Another said, “Sometimes I am and other times not—it depends on the noise the other residents make.”

However, we also saw several environmental risks that could pose safeguarding concerns, such as unsecured windows, high water temperatures, and hazardous items like rodent traps left in shared areas. This put people at risk of harm from falling from height, scalding from high water temperatures or poisoning if they ingested rodent poison.

Staff were given safeguarding training and there was an up to date current safeguarding policy in place. We found that staff had a good understanding of safeguarding and were aware of the risks of a closed culture. Where safeguarding issues were identified, timely referrals were made to the appropriate authorities. The management team had an ‘open door policy’ to aid open communication with staff. The manager said “We complete the investigation and reduce the risk as soon as possible. We learn lessons from it. There are always lessons to be learnt.”

During our inspection we found a person in a very hot bedroom laying in direct sunlight who was being cared for in bed. This person was at risk of overheating, dehydration, and exacerbation of their dementia symptoms. People with dementia are at higher risk of getting too hot or dehydrated, as they may not realise or communicate that they feel unwell. This was raised with the manager and quickly rectified but had not been identified by care staff.

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. We found limited evidence that people were actively involved in managing their own risks.

Risk assessments were missing for known hazards, such as flammable creams and hot environments. This was fed back to the manager during our assessment who took action to address issues we had found.

Care plans and risk assessments did not provide staff with enough guidance on how to support service users safely. Several care plans contained poor-quality or incomplete information, limiting their effectiveness in guiding staff practice.

Care plans did not always reflect people’s preferences or communication needs, and some used language that was not person-centred. For example, one plan described someone as “non-compliant,” which is not respectful. Key details were missing, particularly around individuals communication needs and how to support them during episodes of distress.

Conflicting information was noted in some plans, for example, discrepancies regarding which type of sling should be used for moving and positioning a person. Some care plans included names of multiple different individuals, raising concerns about copy-pasting errors and the overall accuracy of the documentation. These issues had not been identified through internal auditing or review processes, indicating weaknesses in care plan governance and quality assurance. There was a risk that poor quality care or inaccurate recording would not be identified quickly and put service users at risk of harm from an inconsistent approach to their care. The new manager confirmed they were in the process of carrying out a thorough review of people’s care plans to address these issues.

The provider was aware of how to involve people to manage risk including working with family or advocates where needed. The provider ensured that if someone didn’t have capacity they went through a Mental Capacity Act (MCA) Assessment. This helped to ensure that people received fair treatment and advocacy support when needed.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities, and technology supported the delivery of safe care.

We found that checks on the building and safety systems were not thorough. Important problems were missed. We found numerous fire safety concerns, many had previously been picked up in a risk assessment in 2022, but these had not been actioned. We found multiple fire doors were poorly fitting. Additionally, intumescent strips—critical for fire containment—were observed to be covered in paint, compromising their effectiveness. In the event of a fire this would pose an additional risk as the fire evacuation plan had ‘stay put’ protocols in place for some people meaning in the event that they could not be safely evacuated they would remain in a fire safe area. We found that fire drills had taken place during the day, but there were no records of any night-time drills. Planning for emergencies, including full evacuations, needed to be improved.

Personal Emergency Evacuation Plans (PEEPs) were in place but had some information missing such as people’s names. Fire safety signage throughout the premises was inadequate or unclear, potentially leading to confusion during an emergency. One door, which appeared to be a designated fire exit, was fitted with multiple locks and chains, further impeding emergency exit. We contacted Nottinghamshire Fire and Rescue Service who visited Ashlands Care Home and confirmed the fire concerns. However, the provider was responsive and rapidly addressed the concerns which were presenting significant risk of harm to people.

We found that risks from unsafe items were not always well managed. We saw a rodent trap with poison in a bathroom, broken furniture still in use, and rooms that were very hot. Many windows did not have safety restrictors, which increased the risk of falls.

We found that water safety checks, including legionella and temperature monitoring, were being done. However, water from some taps accessible to service users were too hot during our visit, which posed a risk of scalding. We also found that there was no clear system to check if call bells were working properly or being responded to in a timely manner.

People told us they thought the home was clean and tidy. We saw that bedrooms and shared areas were cleaned daily. Many people said they were happy with their rooms.

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.

Staff reported receiving regular training, however we found that many staff had missing or expired training in key areas like Deprivation of Liberty Safeguards (DoLS), fire safety, and dementia care. Staff had not received fire marshal training despite being described as such in the fire evacuation plan. However, staff demonstrated basic knowledge of fire safety procedures, including evacuation routes and assembly points.

Some staff had completed all of their training in just a few days, which raised concerns about their understanding of the topics and quality of the training. There was no clear record of induction or competency checks for moving and handling. Most people felt there were enough staff. One said, “Yes, there are enough staff—I think you always get someone.”

Staff were not always present in communal areas. This meant people who needed support, for example, being observed by staff to ensure their safety, were at risk of harm. Other people who may be at risk of falls may also get up unaided and be at risk of experiencing a falls.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We found that infection prevention and control (IPC) practices at the service were not effective and did not meet the standards required to ensure people’s safety. The environment and equipment were not consistently clean or well maintained, and there were multiple issues of basic hygiene and cleanliness. We found visible dust, cobwebs, and damaged furnishings throughout the home. Hygiene standards were compromised by soiled equipment, including stained pressure cushions which were not named for individual use. There was expired personal protective equipment (PPE) found on-site and an external clinical waste bin left open. Despite previous recommendations, many of these issues remained unresolved, indicating a lack of effective action and oversight. There was a lack of robust systems to assess, monitor, and manage the risk of infection. These failings placed people at increased risk of harm from infection and demonstrated a lack of oversight and accountability in maintaining a safe and hygienic environment.

We found staff had received training regarding infection prevention and control and the use of PPE. The provider had comprehensive and up-to-date infection prevention and control policies in place, which clearly outlined roles, responsibilities, and procedures to minimise the risk of infection transmission. However, this was not being effectively used to prevent and control infection.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacity, and preferences. Staff did not always involve people in planning their support with medicines.

People reported timely access to medicines. One said, “When I needed statins, they arrived the same day.”

We found risk associated with people using specific emollient creams had not been considered. Emollient creams help retain skin moisture, but some can pose a fire risk when absorbed into fabrics and exposed to heat or flames. Emollient creams were also being stored in bedrooms where temperatures were high. This may compromise the stability and effectiveness of the medicine and presents a risk to peoples safety. The provider was responsive to our concerns and took prompt action to address the issues raised.

There were significant issues with the management of ‘as required’ and covert medicines. Records lacked clarity, and there was insufficient documentation to demonstrate that these medicines were being administered safely and in line with best practice. Allergy information was missing from all medication records reviewed. This omission increases the risk of adverse drug reactions and indicates a lack of robust systems to ensure safe prescribing and administration. Medicines were given and discussed in public areas, which affected people’s privacy.

The service’s medicines policy requires that any handwritten or paper-based medication administration record (MAR) charts are signed by two staff members. This policy was not being followed in practice, which undermines the integrity of medication records and increases the risk of errors. This put people at risk of not getting their medicines safely. The manager took action to rectify these issues following our visit.