Ashville Court

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 remained 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.

Staff understood their responsibilities to record and report any accidents or incidents. The registered manager had systems in place to ensure accidents and incidents were regularly reviewed to identify any emerging themes or patterns to mitigate further risks and improve the care provided. Feedback and lessons learned were shared with staff electronically, via meetings and during daily handovers.

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.

Staff planned and organised care and support with people and their relatives before admission into the home, to ensure there was a positive and joined up approach.

Staff worked closely with other medical professionals, such as the district nurses who visited weekly. The local GP carried out weekly calls to review people and monitor their health and well-being, along with face-to-face visits where required.

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.

Staff had completed safeguarding training and understood the different types of abuse, how to escalate any concerns and how to keep people safe.

Safeguarding logs were in place and referrals were made to the local authority, along with relevant notifications to the commission, were appropriate.

Care plans recorded if people had capacity to make day to day decisions for themselves. Where people were subject to Deprivation of Liberty safeguards (DoLS) the service had made applications to the local authority and there was clear monitoring in place. DoLS ensure if a person is restricted in a way that deprives them of their liberty in a care home, it is only done when it is in their best interests, is necessary for their safety, and all other options have been considered.

Staff received training in relation to the Mental Capacity Act.

Relatives told us their loved ones felt safe. Comments included, “[Name of person] is absolutely safe here.”

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff knew people very well and people told us they were involved in developing their risk assessments. People were supported to manage risk while maintaining independence as much as possible. For example, people were assessed on the use of keys to lock their own rooms. This enabled them to keep their items secure whilst offering them independence and autonomy.

Relevant support and equipment were provided where required, to help minimise potential risks. For example, we saw people who were at a high risk of falls had risk assessments in place along with equipment, such as a sensor mat next to the person’s bed and walking aids.

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 environment was well maintained, and audits and systems were in place to maintain it safely. Appropriate arrangements were in place to manage emergencies.

Fire safety checks were carried out to ensure people knew how to respond in the event of a fire and people had personal emergency evacuation plans which were visible in their rooms.

A recent fire authority assessment had been carried out which highlighted a couple of areas of concern. The management team were in the process of actioning these to ensure that people were kept safe.

People had the equipment they needed to help keep them safe, such as wheelchairs and walking aids.

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.

The provider followed safe recruitment practices. Thorough pre-employment checks were carried out, and people were asked to be part of staff interviews, to provide feedback on any future employees. The registered manager had a training matrix in place which evidenced all staff completed mandatory training. This was carried out in split shifts on an annual basis to ensure staff had protected time to complete the required modules. The registered manager also provided extra bespoke training, which had been researched and deemed appropriate for people’s needs, and had created training packs for each staff member. Staff were encouraged to engage with further learning such as National Vocational Qualifications (NVQ).

Relatives told us that there were enough staff to meet their loved ones needs. One person told us, “I think the staff are pleasant, knowledgeable and efficient. They are there on the dot if we need them”.

We observed staff were present in all areas and they did not appear rushed. Call buzzer response times were prompt.

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.

Staff had access to appropriate supplies of personal protective equipment, and we observed this being used correctly. Staff had access to infection prevention and control policies and had completed the required training.

We observed a high level of cleanliness throughout the home, and it smelt fresh during our visit.

A recent Infection Prevention and Control assessment had been carried out by the local authority which scored at a very low level of concern. The minor issues identified were actioned immediately.

Relatives told us, “Ashville Court is lovely. It’s well maintained and it is clean. There is somebody constantly cleaning.”

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Controlled drug registers were not always completed accurately, and we found on 2 occasions where balances had been recorded incorrectly

Staff involved in managing medicines had been trained and had their competency assessed.

Medication administration records had information on people’s allergies and care plans included instructions on how people liked to take their medicines.

For 1 person who received their medicines covertly (hidden in food and drink) staff had completed relevant capacity assessments and documented decisions this was in the person’s best interests. Staff did not have access to information from an appropriate healthcare professional that instructed them on how to give the person’s medicines safely in this way.