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 changed to Good. This meant people were safe and protected from avoidable harm.

This service scored 72 (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. Lessons were learnt to continually identify and embed good practice.

Accidents and incidents were recorded and reviewed so any trends or patterns could be identified. If needed, referrals were made to other services to make improvements or assist with reviewing incidents. Feedback to staff of any changes to people’s care following an incident were communicated in handovers and staff meetings. This helped to reduce the risk to people’s safety.

The registered manager was aware of their responsibility to thoroughly investigate any concerns raised and promote an open culture within the service and was able to give detailed examples of where this had occurred and the steps taken.

People and their relatives knew who the registered manager was and how to raise concerns if they had any. In the entrance area of the building was a notice board with a section for ‘you said, we did’ to showcase where improvements had been made from feedback. This meant people benefited from a service that continually improved through reflection and 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.

The registered manager worked with others to solve problems and make improvements. The service communicated with other agencies to help ensure continuity of care. Regular contact was maintained with the local authority, social workers, GPs, district nurses, and other professionals.

Where people were moving in or out of the service permanently, they were supported to ensure the transition was well managed. The registered manager told us, “We go out and meet the person first, find out what they need so everything is in place when they get here.” If there was an emergency admission senior staff or management staff would sit with the person or their relatives and get the information they need. This meant people experienced smooth, safe transitions between services, reducing risk and promoting continuity of care.

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 had a process in place to report concerns. The management team ensured relevant authorities such as the CQC, and the local authority were informed of incidents or allegations of concern which could affect people’s safety.

People and their relatives felt people were safe, knew the registered manager well and felt able to raise concerns if needed. Staff had confidence any issues reported would be acted on by management. Staff had completed training in safeguarding; they understood their responsibilities and reported any concerns to management. They were confident any concerns would be dealt with but were aware how to escalate issues outside of the organisation if needed.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making 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 make 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 MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS).

Where people needed to be deprived of their liberty to keep them safe, the provider ensured a Deprivation of Liberty Safeguard (DoLS) was applied for through the relevant local authority. Any conditions related to DoLS authorisations were being met. The documentation supported that each DoLS application was decision specific for that person. We saw that the conditions of the DoLS had been met.

This meant people experienced care which protected them from risk of avoidable harm, and abuse and protected their right to live safely.

The provider did not always accurately record the work done with people to understand and manage risks. However, staff provided care to meet people’s needs which was safe, supportive, and enabled people to do the things which mattered to them.

Conflicting information was noted in some care 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. This issue was also identified during the previous assessment. The registered manager acknowledged our feedback and had begun reviewing the area to ensure appropriate improvements were implemented.

Risks were identified and recorded with guidance for staff on how to manage risks. Most support plans and risk assessments accurately identified potential risks to people’s safety and provided staff with enough guidance on how to support service users safely. The registered manager had a good understanding of implementing the least restrictive options for people to ensure people lived better lives.

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

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

We raised a concern about an unlocked upstairs room where hoists were stored, as this could present a falls risk. This was addressed the following day by adding a lock and placing the key securely above the door frame. We also discussed a faulty lift door mechanism which repeatedly closed on a person’s walking frame, making it difficult for them to enter safely. This was shown to the registered manager, who confirmed this was not how it usually operated and agreed to arrange repairs.

Staff demonstrated a clear understanding of the actions they needed to take to keep people and themselves safe. People and staff were involved in fire safety drills, and people had a detailed Personal Emergency Evacuation Plan (PEEP) in place. Checks of utilities and equipment were regularly carried out by external contractors. Staff completed weekly and monthly checks such as water temperatures and fire safety equipment. During our visit, the home was visibly clean and well maintained.

This meant people lived in an environment which was well‑maintained, safe, and supportive of their wellbeing, with risks effectively identified and managed to protect them from avoidable harm.

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 which met people’s individual needs.

Staffing rotas were in place, and this demonstrated how many staff were available to care for people. A dependency tool was used to determine how many staff were required. The provider had safe recruitment practices in place, and all necessary pre-employment checks were completed before staff began working in the home. However, during our review of staff files, we identified gaps in employment history. We discussed the importance of exploring these gaps during the interview process and ensuring this information was clearly recorded.

New staff completed an induction before starting work. Staff told us they were well supported. Staff received regular supervision. Staff completed regular training, to make sure they had the knowledge and skills to carry out their duties. When asked about staff training, the registered manager said, “We ask on supervisions. We have open door policy, but we also observe and if we can see they are lacking[knowledge]we will support them. It might not be official training, it might be a chat with one of us or shadowing.” This meant people received care from staff who were skilled, available, and able to meet their needs safely.

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.

We found a few minor infection control issues, which were resolved immediately. These included removing a shower chair from the shared bathroom and adding a pillowcase to a pillow in one resident’s room. Pressure-relieving cushions were clearly labelled for individual use. The home was clean, well maintained, and free from any unpleasant smells.

Staff were trained in relation to infection, prevention, and control. Staff had access to personal protective equipment [PPE], which included gloves and aprons. Systems were in place to promote safe Infection, Prevention and Control (IPC) practices, such as cleaning schedules and auditing.

People were receiving support from staff with maintaining their personal hygiene and the home was kept clean and well maintained when any issues arose. This meant people were protected from infection and disease.

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.

People were given their medicines safely and in a timely manner. This was recorded on their medicines administration record (MAR) and medicines were stored safely and securely. There were processes in place to ensure the safe and effective use of medicines. Instructions for medicines which should be given at specific times were available. Staff were administering medicines as directed by the prescriber which reduces the risk of the service user experiencing adverse effects from the medicine.

Detailed guidance specific to each person on how to administer medicines prescribed as and when people required them, known as “PRN” was available to staff. The use of topical creams and ointments were recorded on the medicines administration records (MARs). Body maps were in place to show staff the site of application.

There were records of people’s preferences to indicate how they wanted their medicines to be administered. Temperature records to ensure the safe storage of medicines were completed in accordance with national guidance. This meant we could be assured medicines were safe for use.

There was evidence there was a process in place to record medicines related incidents or errors. There were appropriate arrangements in place for the management of controlled drugs (medicines which require extra checks and special storage arrangements because of the potential for abuse).Records showed staff had received medicines handling training. Staff competencies were assessed regularly to make sure they had the necessary skills. Managers and members of staff qualified to handle medicines regularly completed audits (checks) to make sure procedures were followed. This meant people received their medicines safely and effectively, supporting their health and wellbeing.