Ash Court 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 Good. At this assessment the rating has changed to Requires Improvement

This service scored 56 (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. Lessons were learnt to continually identify and embed good practice. The provider had a system for monitoring, investigating and reporting incidents and concerns about safety were investigated and discussed during team meetings. For instance, the home had experienced a high number of falls within a one-month period. Management had identified, through audit and analysis, that falls occurred more frequently in the evenings and proposed increasing staffing levels during these times. Although this action was not implemented consistently, there was a reduction in falls noted in the weeks that followed and appropriate medical attention was always sought when incidents occurred, and many people had equipment in place to help reduce risks. Staff were involved in discussions about safe practice through supervisions, team meetings and daily contact with the registered manager to ensure lessons were learned.

The provider worked with people and healthcare partners to establish and maintain safe systems of care. 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. A healthcare professional told us the provider is very good at seeking support and providing information about new people. However, some information relating to a person’s dietary needs was not communicated with kitchen staff. We raised this with the provider, and this information was updated immediately moreover there was a consistent staff team who knew people well mitigating the risk. We also found some people’s initial assessment plans did not contain enough information about how to meet people’s needs. For example, some people’s diabetes risk assessments were not always completed correctly and had conflicting information. We raised this with the manager, and we were assured this would be rectified. The provider worked well with healthcare professions to improve outcomes for people and advice was sought from healthcare professionals in a timely manner

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The provider shared concerns quickly and appropriately with other healthcare professionals. People felt safe supported by the staff team. One person told us, “I feel safe here, they look after us really well.” Staff understood their responsibilities to safeguard people, and appropriate policies were in place. Leaders and staff showed a good understanding of safeguarding.

The provider worked well with people to understand and manage risks. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Although the provider had created plans to help during episodes of emotional distress. Positive behaviour support plans needed more personal details on how to best support people. People’s needs and risks were not always clearly and consistently documented in care plans. We found that people were using each other’s wheelchairs. We raised this with the provider, and they addressed this by adding clear name tags to the wheelchairs by the end of our inspection. People told us they felt safe living there, one person said, “I can’t walk on my own anymore and they always make sure I have someone to help me if I need to go somewhere.”

The provider did not consistently identify and manage potential risks within the care environment, which meant people were not always protected from avoidable harm. Although the provider ensured that equipment used for lifting people was always within its serviced date to ensure safe lifting of people, some areas of the environment needed attention, for example a radiator cover was found hanging off wall increasing the risk of people injuring themselves. We also found in one of the bedrooms a wardrobe was broken and a curtain pole was broken and hanging off the wall. There was a lack of clear signage in some areas to guide people in the event of an emergency and escape routes were not always kept clear of equipment. These issues placed people at risk of avoidable harm. We raised these concerns with the provider and these shortfalls were addressed immediately.

The provider’s recruitment processes were robust and were completed in line with the provider’s own recruitment policy. The provider made sure staff received effective support, supervision, training and development. A staff member told us, “I feel we are well trained to do the job we do. If there is extra training you need, the manager can provide it for you. There is support at Ash Court, we support each other.” The provider's own survey showed that people wanted more activities. However, staffing levels were not always sufficient to support this. We raised this with the provider, who explained that the activities coordinator was on long-term sick leave, which had impacted the availability of activities. Following our assessment, the provider assigned another staff member to take on these duties in the absence of the activities coordinator. Although the home used a dependency tool to guide staffing levels, we observed some people still in their night clothes at midday. When asked, they told us they had not yet received support with their morning routine.In addition, a staff member told us some people were waiting longer to have their personal care needs met in the morning due to not having enough staff, they said, “The ratio needs to be bigger, it has been mentioned before to management, but these ratios are in line with HC One policies, so there is not much we can do.”A relative told us, “There seem to be no staff visibility especially at the weekends. You ring the bell and staff take time to answer. It can be frustrating.” When we raised this with the provider, we were told, management will step in to support with numbers if needed.

The provider did not always assess or manage the risk of infection. The provider completed infection control audits on a regular basis. Staff told us PPE and all cleaning materials needed were available and they confirmed they had received infection control training. However, soiled PPE was found hanging by the PPE station hampering effective infection control. We discussed this with provider the infection prevention control implications and these issues were addressed before the end of the inspection. Although there was a good standard of hygiene, not all areas of the home were maintained in a way which safely supported effective infection prevention and control practices. For example, we found communal bathrooms and toilets with stained flooring and unpleasant odours. Upon raising this with the provider, they took immediate action and deep cleaned the stained floors prior to the end of our assessment, and we were assured the unpleasant odours will be addressed. We spoke to kitchen staff and laundry staff who told us they had received training regular updates about infection control guidance and support from the provider.

Although the provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences, we found one person’s medicines which required to be given alone, 30 minutes before food were given together with other medicines without appropriate documentation from a doctor or pharmacist. This was later rectified by seeking support from healthcare professionals and clearly documented in the person’s file. We also found in some instances some people had other peoples’ topical creams in their bedrooms, however, this was later rectified by the registered manager. Staff medication competency checks were up to date, however training records for medicines were not always up to date. We raised this with the provider, and we were assured training had been completed, the issue was the system was faulty and had not been updated, training records for medicines were not always up to date. We raised this with the provider, and we were assured training had been completed, the issue was the system was faulty and had not been updated. Records of regular medicines were well-maintained and followed national guidance including recording people’s allergies. Staff used an electronic system to record they had administered people’s medicines. People told us they received their medicines in a manner which suited them.