Ashley Court Care Limited

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 inadequate.

This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulations in relation to people’s safe care and treatment, medicines management and staffing.

This service scored 28 (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 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.

The systems in place to ensure lessons could be learnt and improvements made to the service where needed were not effective. At our last inspection we requested an action plan from the provider to demonstrate how they were going to make improvements and comply with regulations. We found they had not always taken the action they told us they had which meant improvements had not been made and they remained in breach of the legal regulations including the Regulation related to safe care and treatment.

When incidents had occurred, although this information was analysed there was not always evidence to show what actions were being taken or how this information was used, to consistently learn lessons, make changes or drive improvements.

The provider told us they considered learning from safeguarding incidents in the home. Records we viewed showed that some learning was identified from safeguarding incidents. However, improvements could be made to ensure learning was effective and sustained.

The provider did not ensure, establish and maintain safe systems of care.
There were systems in place to ensure people’s needs were assessed before they started using the service. This included completing a pre assessment about people’s needs which where possible was face to face. The deputy manager told us care plans and risk assessments were put into place for people based on their assessed needs.
However, we found these processes were not followed. One person who had recently moved into the home had no individual care plans or effective /comprehensive risk assessments in place. We saw they were unsafely supported during our inspection. The pre assessment that had been completed for this person also lacked detail on the person and how they may need to be supported.
Other people had care plans and risk assessments in place however they were not always updated when changes or incidents occurred. It was not always clear how people and those that were important to them were involved with the process. This placed people at risk of receiving unsafe and/or unsuitable care.

The providers systems to ensure people who were deprived of their liberty in line with the MCA principles were not consistently effective.
People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that when needed, DoLS were in place for people, however we could not view the content of these as they were password protected, and no one could access these. This meant some people may have conditions in place which we were unable to view, we could therefore not be assured if these were being met or not.
The provider sent us a copy of the DoLS tracker however we could not be assured it was accurate and up to date as the information on the tracker did not match the information contained in a person’s care plan.
People felt safe living in the home. One person said, “I feel safe here, there are staff around and the front door is locked”. There were systems in place to ensure when safeguarding concerns were identified they were reviewed and investigated. Staff told us they had received training and were able to tell us the action they would take if they were concerned.

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.
At our last inspection we found concerns with the management of risk, at this inspection we found the necessary improvements to keep people safe had not been made.
There were no individual care plans or risk assessments in place for a person who had recently been admitted to the home. We saw their legs were hanging through their bedrails which had not been assessed as safe for the person to use. We also saw they were walking without any shoes on despite being identified as high risk of falls.
Another person had been referred to a health professional due to sore skin. We observed this person was seated in a wheelchair, with no cushion [or pressure cushion] for a long period. This placed this person at risk of further sore skin.
The records in place for this person was also inaccurate as it stated they should stand when other records told us they needed to be hoisted. For this person and other people who were not independently mobile it was unclear who had assessed their needs and the equipment they may need to keep them safe.
We asked to see input from professionals during and after our inspection however this was not fully provided. We were told the deputy manager had completed the assessment and made the recommendations however they confirmed they did not have the qualification, skills or knowledge to do so. This all-placed people at risk of harm.
We viewed an incident record which stated another person had an unwitnessed fall, this person’s care plans and risk assessments had not been reviewed since this fall had occurred which meant no action had been taken to reduce the risk of falls reoccurring, placing this person at risk of further falls and potential harm.
However, people were generally happy with how their risks were managed and we did see that some people had care plans and risk assessments in place that reflected their needs for example, when they were on a specialist prescribed diet.

The provider did not always detect and control potential risks in the care environment.

At our last inspection we found concerns with the safety of the environment. At this inspection we found some of the concerns raised previously had been addressed, however new environmental safety concerns were identified. This meant effective systems were not in place to ensure people were consistently protected from the risks associated with the home environment.
We observed there were areas of the home that were not safely maintained.This included a radiator cover in the downstairs corridor, which was coming away from the wall, exposing a heater and various unlocked doors and cupboards which had warm and hot piping present, which placed people, staff and members of the public at risk of harm
We saw some people had metal bedrails in place. They did not look safe or secure. For example, 1 person’s bedrails were fitted at an angle and not up straight. We saw these people had portable material bumpers fitted to these bedrails, again they appeared not to correctly fit and there were areas of the metal bedrails that were exposed. People were in bed at the times we saw these bedrails.
We saw some people had a bedrails risk assessment in place which gave measurement and requirements of the bedrails and bumpers. Staff told us and records confirmed the measurements of this equipment were not being checked and therefore we were not assured they met the requirements needed, placing people at risk of injury and harm.After our inspection the provider told us they had taken action to resolve this, we will therefore review this as part of our next inspection.
The systems and audits in place to monitor the environment had not identified these concerns.

The provider did not always make sure there were enough staff available to support people.

We received mixed feedback from people and relatives about the staffing levels in the home. One person told us, “I press my bell, and the staff come, it can take a while at busy times, mainly weekends, but it hasn’t caused me a problem”. A relative said, “I don’t think they have enough staff to keep the home as it should be”.

We saw throughout the inspection staff did not interact with people unless it was specifically about tasks. There were periods of the day where staff were not present in communal areas to offer support to people as they were supporting people in their bedrooms.

Different areas of the home were secured. This included the front door. We observed people standing at these points waiting for periods of time to gain access to their bedrooms as there were no staff available to offer support and open these areas. One person became frustrated and vocal when they could see their family were waiting to come into the home.

We saw people had to wait for support as staff were completing other tasks.

At our last inspection we found concerns with how the dependency tool was completed, at this inspection we found the necessary improvements had not been made.

There was a dependency tool in place that was used to work out the number of staff needed in the home. However, this was not accurately completed. It had not been reviewed since a person had been admitted to the home and therefore did not calculate the correct amount of people living in the home. It also showed 4 people were assessed as having ‘high needs’, this meant they needed 2 staff for transfers or moving and handling. The records and observations we made showed at least 7 people needed 2 staff and therefore were assessed as having ‘high needs’. This meant the provider had failed to correctly assess people’s needs to ensure there were enough staff available to support.

Staff told us and records confirmed they had received mandatory training. However, staff had not received training in the management of seizures despite a person living in the home having experienced seizures. Staff we spoke with were able to tell us what they would do in an emergency. This meant the provider had not ensured staff were suitably trained to provide safe care and support to people.

Staff had received the relevant pre-employment checks before they could start working with people to ensure they were safe to do so.

The provider did not assess or manage the risk of infection. They did not detect and therefore did not control the risk of it spreading.At our last inspection we found concerns with the cleanliness of the home. At this inspection we found the necessary improvements to keep people and their environment safe had not been made.
We received mixed feedback on the cleanliness of the home. A relative told us, “I made a complaint in July about the state of the cleaning, the whole home is grimy, I have bought my own mop and cleaning wipes to do my [relations] room. Things improved for a short while but then slipped back”. Other people raised no concerns.
We viewed intelligence that we held about the service since our last inspection, which included various members of the public and people living in the home raising concern about IPC and the cleanliness of the home.The home was unclean and there was a strong odour throughout, this was more prominent in some areas.We saw areas of the home that required cleaning or posed as an infection control risk. This included, toilets, a commode (which was also rusty) and a towel that had faeces on them for the duration of the inspection.
Clinical waste bins did not contain a clinical waste bag and remained like this for the duration of the inspection. One of the bins had some items disposed of in which meant you would have to handle these items to remove them. We observed a plastic glove that was dirty was left on the sink in a communal bathroom for the duration of our inspection.
In a person’s bedroom there were bits of food on the floor. The food remained on the floor for the duration of the inspection.We observed various toilet roll holders were broken and therefore toilet roll was stored in other areas within bathrooms.We also observed a staff member administer medicines to a person. After completion we saw they went into the medicines room and did not wash or hand gel their hands before administering another person’s medicines. This all-placed people, staff and members of the public at risk of cross infection.
We found a cupboard was stocked full of linen. Some of this was stored on the floor, was unfolded and it was unclear what order this had been placed into the cupboard. This meant the provider had not followed correct procedures in relation to the storage of linen and placed people and staff at risk of cross infection.

The systems and audits in place to monitor IPC had not identified these concerns.
 

The provider did not always make sure that medicines were administered safely, disposed of or stored safely.At our last inspection we found concerns with the management of medicines, at this inspection we found the required improvements relating to the management of ‘as required’ medicines and the management of medicines stock had been made. However, during this inspection, new concerns with medicines management were identified that showed a continued concern around medicines management at the service.
We saw a staff member administering medicines to a person. They emptied a powder medicine into glass of water. The person drank approximately half of the medicines/drink before the staff member took it away. We viewed the medicines administration record (MAR) for this person. This recorded this medicine as administered which is not accurate as we saw the person did not drink all of this. This meant the person did not receive this medicine as prescribed or as documented. Furthermore, when the staff member took the medicines away, they placed it on a trolly of empty/unclean cups that was stored in the communal dining room, where other people, some living with dementia were present. This medicine was not stored or disposed of safely and this placed people at risk of harm should they ingest this.

On arrival we saw a staff member walk past a tablet that was stuck to the carpet. This staff member appeared to not notice the tablet, therefore we alerted the deputy manager to this. We asked the staff member who was administering medicines about how the tablet had been disposed. The information they told us raised concerns as they told us there was no disposal book in place when we saw there was. The deputy manager also brought to us a controlled drug destruction kit, to show us how this tablet should be disposed of, which is not the correct procedure for disposing of this medicine. This meant the staff responsible for medicines administration and the monitoring of this at the time of the inspection did not fully understand the procedures that were in place in relation to the management of medicines.
It was unclear what action had been taken with the tablet we had found or where this had come from. We gave the provider the opportunity to complete an investigation. The information they shared with us after the inspection raised further concerns. They told us despite them being responsible for managing a person’s medicines the person also brought their own medicines into the home. There were no care plans or risk assessments in place that identified this risk or how this was safely managed.
People raised no concerns with how their medicines were administered. We found ‘as required guidance’ was in place, stock checks were accurate, and staff had received training in the management of medicines. However, we could not be assured all staff responsible for administering medicines were competent as the staff member responsible for medicines administration on the day of the inspection did not know how to dispose of medicines and when asked were not aware what ‘as required’ protocols were.