Ashring House

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 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Whilst the provider promoted a proactive and positive culture of safety based on openness and honesty, there had been concerns raised in respect of people’s safety and well-being. We looked at how staff took this forward and found that there had been no formal discussions or reflections held about how to prevent and mitigate risks to people. Lessons therefore had not always been learnt to continually identify and embed good practice at staff level. The provider told us that they had been discussed but not added to the log. This has now been resolved.

The management team confirmed that changes have been made in respect of more robust reporting and following up of all incidents. For example, an incident concerning food which had had a negative impact on people, had now been taken forward and actions taken to educate staff and devise alternative menus.

The organisation has also provided a “Lesson learnt newsletter” that all services and staff had access to. This newsletter included key moments over a period of time, what worked well, what could have gone better and how to improve moving forward.

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.

People’s move into the service was planned and focussed on what best suited the person themselves and their families.

When people moved or were admitted to hospital, staff worked with other managers and professionals to ensure smooth transitions and that all necessary paperwork was up to date. A hospital passport which was a condensed care plan and contained key information about people was used when a person had to go to hospital. During hospital visits and overnight stays, staff from the service would accompany people and remain with them throughout their visit. A senior staff member told us, “If someone needs to go to hospital, we send one of their key workers with them to reduce anxiety and help settle them.” A health professional said, “We have had no concerns about the support given by staff when they have gone to hospital.”

Staff worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The provider had told us they had were committed to improving people’s lives, while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. However, there had been missed opportunities to address issues regarding alleged poor practice, and poor communication between the staff at the service and this had the potential to impact on the outcomes for people and staff. Since these concerns had been raised and brought to the attention of the senior management team, action had been taken to engage with all staff. They had also introduced safe systems to support staff to raise issues. For example, representatives from the organisational human resources team had visited the home regularly along with engagement visits from the local authority market support team.

The provider investigated safeguarding incidents and shared concerns quickly and appropriately with the relevant authorities. Any outcomes were shared with the person and their family as appropriate.

Safeguarding and whistleblowing policies were in place at the service and were regularly reviewed. Managers and staff were confident of the steps they would take if they came across a safeguarding situation and staff also told us they were confident to use the whistleblowing process if needed. Whistleblowing is a legal process where concerns can be reported anonymously by staff. Staff had received training in safeguarding and were able to tell us of situations that would amount to an issue that needed reporting. We observed safe practice when staff were supporting people 1 to 1 during our visits. Staff attended to their needs in a safe way, safeguarding them against injury and promoting their well-being.

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. For example, regarding restrictive practices such as lap straps. We saw that the conditions of the DoLS had been met.

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.

Effective systems were not always in place to assess, monitor and mitigate risks to people and keep them safe. We identified some people’s needs were at risk of not being met in respect of management of continence and catheter care, choking, epilepsy and dementia. Also, the risk of entrapment in bedrails had not been considered following a change in bed following a recent hospital stay. This was because not all documentation was up to date and reflective of recent events or incidents that impacted on their care needs.

Not all people that were at risk of choking had a risk assessment for actions to be taken or a care plan that guided staff in the prevention of choking.

Where people lived with a dementia diagnosis there was a lack of direction for staff of how to manage these changes alongside their learning disability diagnosis. For example, care plans did not include up to date guidance for staff about how these impacts on their daily life and the new challenges this brings to the person daily.

Daily records were not always consistent in documenting care delivery, peoples’ social and well-being which meant that changes in peoples’ health and well-being were not being monitored and may be missed. The care plans and risk assessments were updated, and bedrail covers were put in place by the 2nd site visit.

Risk assessments supported staff to manage identified risks whilst ensuring people's rights and independence was promoted and respected. Positive risk taking was supported and encouraged in line with the principles of registering the right support, right care, right culture to help people learn new skills, to enhance their lives.

Staff received training in areas of potential risk such as moving and handling, first aid and health and safety. All staff had recently received fire training and undertook day evacuations to ensure all staff have confidence in the event of fire to manage people safely. A night evacuation was planned. Personal Emergency Evacuation Plans (PEEPS) had been completed for each person. PEEPS give staff or the emergency services detailed instructions about the level of support a person would require in an emergency such as a fire evacuation. These were being updated to ensure they were reflective of peoples’ current needs

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. There were regular safety checks being completed by qualified external contractors. People and their relatives told us they had access to the equipment they needed to stay safe. The fire panel system was accessible in the main reception and there was clear signage with floor plans and emergency exits displayed. All areas of the service had clear fire safety signage available. There was a record of all the fire drills which took place, what went wrong, and actions taken to rectify this. Staff were aware of their responsibilities in relation to the fire evacuation process.

Health and safety checks had been undertaken to ensure safe management of utilities, food hygiene, hazardous substances, and moving and handling equipment. Premises risk assessments and health and safety assessments were reviewed on an annual basis, which included gas, electrical safety, legionella and fire equipment.

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.

We observed interactions between people and staff; people appeared to be in control of their day and were relaxed in the company of staff. Staff were knowledgeable and showed a good understanding of people they supported. Staff had undertaken training in how to support autistic people, and how to support people with a learning disability and their skills and competency were regularly assessed. Staff told us, “I've had training for learning disability, moving and handling, food hygiene and autism and many others. We get enough training.”

New staff went through a thorough induction process and were supported with regular supervision meetings and spot and competency checks. Staff were fully trained in all key areas for example, medicines, epilepsy management and moving and handling.

Staff were recruited safely. The provider undertook checks on new staff before they started work. This included checking their identity, their eligibility to work in the UK, obtaining at least 2 references from previous employers and Disclosure and Barring Service (DBS) checks. The DBS helps employers make safer recruitment decisions and prevent unsuitable people from working with vulnerable people.

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. The service was clean throughout. Some chairs were being replaced as the covering was cracked and therefore a cross-infection risk. Staff had all received training in infection prevention and control (IPC) and there was a large supply of personal protective equipment (PPE) which was used appropriately by staff.

IPC and PPE policies were in place and were reviewed each time government guidelines were updated.

Overall, the provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We found some minor shortfalls which were immediately addressed. Staff involved families in planning, including when changes happened.

Staff supported people to have their prescribed medicines and followed best practice for administering medicines. Staff documented medicines in care plans and made them available when people moved between healthcare settings.People could not share their views regarding medicines, but families told us, “The staff do keep us informed of any changes.”

The staff worked closely with the GP and the Medicines Optimisation in Care Homes team, (which is a program by NHS England, which focuses on improving medication management for residents) to ensure medicines were reviewed regularly. The staff were aware of the protocols about Stopping Over Medication of People with a learning disability, autism or both (STOMP).

There were no dedicated clinical room and peoples’ medicines were stored in an appropriate lockable cupboard in their bedrooms with their individual medicine administration record (MAR). Bedroom temperatures were checked and recorded daily to ensure medicines were stored at the correct temperature. Stock of medicines were kept in a lockable cupboard next to the staff office.

Staff who gave medicines had the relevant knowledge, training and competency that ensured medicines were handled and stored safely. We observed staff giving medicines safely and that they were recorded accurately on the medicine administration record (MAR.) Risk assessments were in place for certain medicines. However, there was no anti-seizure (remedy) medicine for one person who had had seizures in the past year. This was immediately taken forward and discussed with the GP.

All discrepancies and medicine errors were recorded and investigated and action taken as required. There was some inconsistency in how staff checked daily stock numbers, and this was addressed during the site visits. Daily checks and monthly audits were carried out, and any shortfalls were addressed. Protocols for 'as required' (PRN) medicines such as pain relief medicines were in place however, they lacked individual personalisation and were not robustly linked to a pain care plan or pain tool. On discussion with staff, they were able to discuss how people showed they were in pain or discomfort, but this was not easily found within people’s documentation. This was fully acknowledged by the management team and was being addressed