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 inadequate. At this assessment the rating has remained inadequate.

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

The service was in continued breach of legal regulations in relation to people’s safe care and treatment which included, 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.

There was not an effective learning culture at the service.

Relatives shared their concerns to us about how incidents were managed within the home. A relative told us, "No one rang us after the incident. There was a lot of confusion about what happened and what was said." Another relative said, "I'm annoyed about the accident and them not being able to find any evidence or proof about what happened."

Records demonstrated incidents and accidents were not always recorded through the provider's incident reporting system. Whilst falls were included within monitoring processes, other incidents, such as seizures, skin tears and bruising, had not consistently been recorded as incidents. This limited the provider's ability to review events, identify trends, consider whether safeguarding referrals were required and take action to reduce the risk of recurrence.

For example, concerns relating to a person's vacant and unresponsive episodes had not been recorded through the provider's incident reporting system. As a result, there was limited evidence that these incidents had been formally reviewed, analysed or considered. This failure to record incidents exposed the person to a risk of avoidable harm because the provider could not demonstrate that appropriate action had been taken to reduce the risk of further episodes or deterioration in their health.

During the first day of the assessment, we identified concerns with the provider's incident reporting process. We raised these concerns with the provider and sought assurance regarding the action they would take to address them.

In response, the provider introduced an incident reporting protocol and told us that incident reporting and management processes would be strengthened.

During the second day of the assessment, we reviewed the action the provider told us they had taken. However, concerns remained. For example, incident reports relating to a person who experienced vacant and unresponsive episodes did not contain key information required by the person's care plan, including the duration of the episode and details of observations undertaken prior to the incident. This meant the provider could not demonstrate that the person's episodes had been appropriately reviewed or that action had been taken to reduce future risk.

As a result, the action taken by the provider was ineffective in addressing the issues we found which meant there was a continued risk of incidents not being reviewed to protect people from the risk of reoccurrence of incidents and support learning.

The provider did not always have effective systems in place to assess, monitor and manage risks to people's health, safety and welfare.

Care plans, risk assessments and monitoring records were not always updated to reflect changes in people's needs, incidents or identified risks. We found records continued to contain inconsistencies and unclear guidance, which meant staff could not always demonstrate how care should be delivered in line with people's assessed needs. For example, 1 person's records contained conflicting information regarding their dietary requirements, with different sections of the care record recording different food textures. This meant staff did not have clear and accurate information to guide how they supported the person. On the second day of assessment the staff member supporting this person to eat their meal was not aware of the diet they should be receiving. This increased the risk of people receiving inconsistent or unsafe care.

We also found changes in people's needs were not consistently reflected within care records. For example, despite 1 person experiencing multiple vacant and unresponsive episodes requiring emergency healthcare intervention, care planning and risk management guidance was not in place. This meant staff did not have accurate guidance to support the person, this exposed them to the risk of receiving unsafe and inconsistent care.

However, the provider had systems in place to assess people's needs prior to admission and had taken some action to update care plans and risk assessments following concerns raised during the first site visit. Whilst this demonstrated a willingness to improve, a number of concerns remained during the second site visit.

The provider did not always work effectively with people, those important to them and partner agencies to ensure people were protected from the risk of abuse, neglect and avoidable harm. We were not assured that safeguarding concerns were consistently identified, investigated and escalated appropriately.

Feedback from relatives was mixed. Whilst some relatives told us they felt their family members were safe, others expressed concerns about their relatives' safety and wellbeing.

A relative told us, “I’m not assured at the minute that they are safe and looked after," and another said, “The ambulance people said they were really concerned (person’s name) are being neglected.”

Records demonstrated that incidents and accidents were not always recorded through the provider's incident reporting system. This meant not all concerns had been appropriately reviewed or considered for safeguarding referral.

During both site visits, we identified concerns regarding a person’s dietary needs. Care records stated they required a Level 6 Soft and Bite-Sized diet; however, staff supporting the person were unable to accurately describe their dietary requirements and the additional checks the provider had told us after our first site visit that would be introduced were not being carried out. This meant there was a risk that the person could receive food that was not in line with their assessed needs, placing them at risk of choking or other avoidable harm.

Despite these concerns being identified during both site visits, the local safeguarding authority confirmed they had not received a safeguarding referral from the provider. Following the inspection, we made a safeguarding referral regarding these concerns. This meant safeguarding concerns were not consistently recognised, assessed and referred appropriately.

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.

The provider did not always work well with people to understand and manage risks. Staff did not consistently provide care that was safe, supportive and reflective of people's assessed needs.

At our previous assessment, we identified concerns regarding the assessment and management of risks and told the provider to take action. During this assessment, we found improvements had not always been made to ensure people were safe.

Records showed one person had experienced multiple falls from bed. Despite measures being in place to reduce the person's falls risk, records did not demonstrate these measures were consistently effective in keeping the person safe. The provider could not accurately determine how long the person had remained on the floor following a fall and records did not demonstrate welfare checks were consistently completed. This meant risks associated with falls were not always effectively monitored and managed.

We also found concerns regarding the management of risks associated with skin integrity. Records showed some people required two-hourly repositioning to reduce the risk of skin damage; however, repositioning records demonstrated significant gaps between interventions despite this being identified within their care plans. This meant the provider could not demonstrate risks associated with skin integrity were being managed in line with people's assessed needs. As a result, people remained at risk of avoidable harm associated with pressure damage.

These findings demonstrated risks were not always effectively assessed, monitored and managed to ensure people received safe care and support.

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

At our previous assessment, we identified concerns relating to environmental safety and told the provider improvements were required. During this assessment, we found some of the previously identified concerns had been addressed. For example, bed rail risk assessments had been reviewed, and appropriate radiator covers were in place. However, the provider's ongoing monitoring and oversight of the environment was not effective. Whilst some environmental concerns had been identified through the provider's maintenance processes, risks were not always addressed in a timely manner.

During the assessment, we identified a leaking shower room, broken toilet seats and detached tiles in a bathroom. We also found rubbish obstructing a fire escape route, which was later removed by the provider but had not been identified as risk prior to our intervention. These findings meant people were not always protected from risks associated with the environment.

We also identified concerns regarding the security of an upstairs gate. On arrival, the stair gate providing access upstairs could not be secured as there was no functioning lock or keypad in place. As the service supported people living with dementia, this increased the risk of people accessing areas unsupervised.The provider took action during the assessment to ensure the gate could be secured.

We also found concerns relating to fire safety oversight. On arrival, we observed a door displaying fire door signage which was locked and required a key to open. Staff were unable to immediately access the area and it took over 10 minutes for a key to be located before the door could be opened. This raised concerns that, in the event of an emergency, people could not access the area promptly. The provider subsequently advised this was not a fire door and removed the signage.

Although some environmental issues had been identified and actioned by the provider, audits and monitoring processes had not identified all the concerns found during the assessment . These findings meant environmental risks were not consistently identified, assessed and addressed in a timely way to keep people safe.

The provider did not make sure there were enough qualified, skilled and experienced staff.

At our previous assessment, we identified concerns regarding staffing, training and staff competency and told the provider improvements were required. During this assessment, we found not enough improvement had been made to ensure people received safe, timely care and support. Concerns remained regarding staff competency, staff deployment and the oversight of agency staff.

The provider did not always ensure suitably skilled, competent and experienced staff were deployed to meet people's needs safely and effectively. We found a high use of agency staff working within the home. Whilst the provider had taken steps to recruit additional staff, they could not always demonstrate that staff had the skills, knowledge and competency required to meet people's needs safely and effectively.

Some relatives raised concerns regarding staffing consistency and competency. One relative told us there had been, "Staff coming and going," and described agency staff as, "Not attentive and knowledgeable to what is going on." These concerns were consistent with whistleblowing information received during and after the assessment.

We identified concerns regarding staff knowledge and competency. We found not all staff had completed epilepsy training despite supporting people who experienced seizures and unresponsive episodes. During the assessment, we observed staff did not immediately recognise and respond when a person experienced an unresponsive episode despite being present nearby. We also observed a member of staff undertaking a hoist transfer; however, the provider was unable to provide evidence they had completed a practical moving and handling competency assessment. These findings meant not all staff had the skills, knowledge and competence required to support people safely.

Furthermore, whilst staff had received safeguarding training and were able to describe safeguarding procedures, we found not all safeguarding concerns were always recognised and escalated appropriately. This meant staff did not always apply the training in practice, which exposed people to the risk of harm.

Although the provider's dependency tool indicated sufficient staffing hours were available, people did not always receive support in a timely manner. During lunch service, which started at approximately 12:30pm, one person did not receive their meal until 1:25pm and another until 1:39pm. One person told us, "I often have to wait a long time for help when I call for help." These findings indicated staffing resources were not always being deployed effectively to meet people's needs.

Whilst staff generally spoke positively about staffing levels, and one staff member told us they were, "Not concerned with the number of staff," our findings, feedback from people and relatives, and whistleblowing information did not consistently support this view.

The provider did not always prevent and control the risk of infection. Systems and processes were not consistently effective in ensuring people lived in a clean, safe and hygienic environment.

At our previous assessment, we identified concerns relating to infection prevention and control and told the provider to take action. During this assessment, we found some improvements had been made; however, concerns remained, demonstrating not enough improvement had been made.

During our assessment, we identified a number of cleanliness concerns throughout the service. We found faecal matter on a toilet lid in 1 bathroom, toilet paper containing faeces and a soiled continence pad on the floor of another room, food debris on floor in a bedroom and strong odours of urine in parts of the home.

These findings did not provide assurance that cleaning schedules and infection prevention and control measures were consistently effective in maintaining a clean and hygienic environment.

Whilst cleaning staff were present during the assessment, we continued to identify cleanliness and hygiene concerns within the service. This demonstrated that infection prevention and control concerns were not always identified and addressed in a timely manner.

Feedback from relatives was mixed. One relative told us their family member was, "Clean" and said, "I've never seen them not clean in all the times I've been there." However, another relative raised concerns regarding personal care and hygiene and told us they had found their family member's nails were very long with blood underneath them from scratching.

The provider did not always ensure medicines were managed safely. Systems for monitoring, accounting for and disposing of medicines were not always effective.

At our previous assessment, we identified concerns regarding medicines disposal processes and told the provider to take action. During this assessment, we found not enough improvement had been made.

On the second day of the assessment, records and observations identified concerns regarding medicines disposal and stock management. We found unused medicines from the previous month's medicines cycle stored awaiting disposal. For example, medicines identified for disposal and medicines carried forward from the previous cycle were stored together in the same container. Staff explained some stock discrepancies related to medicines which had been carried over from the previous month; however, medicines had not been clearly segregated. This meant the system relied on staff knowledge to determine which medicines had been refused, which had been carried forward and which remained following hospital admissions or changes in treatment.

We identified inaccurate stock balances, including medicines being recorded as having inaccurate or no stock available despite the medicines being present within the disposal box. We also found medicines that had been discontinued by the GP remained in the medication tray alongside current medicines. In addition, the medicines disposal record was blank and did not evidence any medicines had been returned for disposal during the month.

This meant the provider could not always accurately account for medicines held within the service or demonstrate that medicines were appropriately segregated following changes to treatment. The provider was also unable to demonstrate a clear audit trail for medicines awaiting disposal. This increased the risk of medicines errors and did not provide assurance that medicines were managed safely. However, we observed some positive medicines management practices. Staff responsible for administering medicines knew people well and were able to describe their medicines and support needs. We observed medicines being administered in a calm and respectful manner, with staff taking time to support people and explain the medicines they were receiving.