Ashby 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 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 followed the provider’s policies and procedures for reporting safety incidents. Incidents were reviewed and investigated to identify contributing factors, trends and any lessons that could be learned. The registered manager maintained oversight of incidents and ensured appropriate action was taken to reduce risks and help prevent similar events from occurring. Learning was shared with staff to support continuous improvement and promote safe, person-centred care.

Information about incidents and any changes to people’s support needs was communicated effectively through staff handovers and updates recorded on the electronic care system. This ensured staff had access to current information and could respond consistently to people’s needs.

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.

There was a clear pre-admission process in place to ensure comprehensive assessments were completed before people moved into the home. These assessments enabled staff to meet with individuals, understand their needs and preferences, and determine whether the service could support them safely and effectively. One relative told us, “There were lots of questions asked before [person] moved in, which really helped staff understand their needs.”

People’s relatives and representatives were involved in the assessment process and provided valuable information about their loved one’s life history, routines, preferences and support needs. This helped staff develop personalised care plans and promote continuity of care from the outset.

People were encouraged to personalise their bedrooms with belongings from home, such as photographs, ornaments and pictures. This helped with transitions into the service, creating familiar and meaningful surroundings, supporting people to feel comfortable, settled and at home in their new environment.

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.

Effective systems and processes were in place to protect people from abuse, harm and discrimination. The provider had clear safeguarding policies and procedures, which were readily accessible to staff. Staff demonstrated a good understanding of their safeguarding responsibilities and were able to explain how they would recognise, respond to and report concerns. They were confident in following the provider's procedures and understood their role in keeping people safe from harm and neglect.

Relatives told us people felt safe living at the home and spoke positively about the care and support provided by staff. Feedback indicated people were supported by staff who were caring, attentive and responsive to their needs, which helped them feel protected and secure. One relative told us, “Staff treat mum very well,” while another said, “I think they are really good and quite kind.” These comments demonstrated people received support from staff they trusted and felt safe around.

The provider worked closely with the local authority and other relevant agencies to safeguard people. Concerns were reported appropriately and without delay, helping to ensure people received the protection and support they needed.

People can only be deprived of their liberty where this is lawful, necessary and in their best interests to ensure they receive appropriate care and treatment. The Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) provide the legal framework for this process when there is no less restrictive way to meet a person's needs. Where a DoLS authorisation is granted, specific conditions may be applied to ensure any restrictions remain proportionate, necessary and respectful of the person's rights and freedoms.

The registered manager maintained oversight of MCA and DoLS processes. Systems were in place to monitor the status of applications and authorisations, track review dates and ensure renewals were requested when required. This helped to ensure any restrictions placed on people remained lawful, necessary and in their best interests, while promoting and protecting their rights.

Where required, concerns and incidents were reported promptly to relevant external agencies, including the local authority safeguarding team and the Care Quality Commission (CQC). This demonstrated a commitment to openness, accountability and effective partnership working to safeguard people and promote their wellbeing.

The provider had processes in place to assess and manage risks to people's health, safety and wellbeing. While staff were generally knowledgeable about individual risks and many risks were managed effectively, we found examples where planned risk management strategies were not consistently followed. This meant people were not always supported in line with their assessed needs, and risks were not always managed as effectively as intended.

People had risk assessments and care plans in place which included guidance on repositioning to reduce the risk of pressure damage. However, records showed staff did not always follow people's repositioning schedules. As a result, measures put in place to manage identified risks were not consistently implemented, increasing the risk of skin deterioration and discomfort for people. We raised these concerns with the provider during the assessment. The provider responded promptly by reviewing care records, reinforcing expectations with staff and implementing additional oversight measures to help ensure people received repositioning support in line with their assessed needs.

Positive Behaviour Support (PBS) plans were in place to help staff understand people's needs and respond appropriately when they experienced distress. Plans included details of potential triggers and strategies to reduce the risk of behaviours escalating. However, records did not always identify all the behaviours of distress that were observed and recorded, meaning staff did not always have the guidance and strategies in place to respond consistently. This reduced the effectiveness of the planned interventions and meant people were not always supported in the way identified as most beneficial to meet their needs, reduce distress and promote their wellbeing.

We observed staff transferring people using wheelchairs without consistently applying the wheelchair brakes before supporting people to move. This presented a risk of the wheelchair moving unexpectedly and increased the risk of falls or injury. We raised our concerns with the management team during the inspection. Leaders took immediate action by addressing the issue with staff and reinforcing safe moving and handling procedures. While managers responded appropriately once concerns were identified, the observation demonstrated that safe practices were not consistently followed in day-to-day care.

One relative reflected on the challenges created by staff changes, telling us, "The staff are brilliant but there has been a huge changeover recently and some get [name] instantly and some don't." This feedback was consistent with our findings and highlighted the importance of staff having a thorough understanding of people's individual needs and the support strategies in place to achieve positive outcomes.

Other risks to people’s health and wellbeing were managed. Relatives generally felt risks were managed to help keep their family members safe. One relative told us their family member was safe because staff were constantly monitoring everybody. Other relatives described measures in place to reduce risks, including pressure mats and environmental adaptations to reduce the likelihood of falls.

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 service demonstrated a proactive approach to environmental safety, with a range of measures in place to reduce risks while maintaining people's comfort and independence. Safety features throughout the home included wardrobes securely anchored to walls, protective covers fitted to radiators to minimise the risk of burns, and window restrictors installed to reduce the risk of falls from height. Regular electrical safety checks, fire risk assessments and maintenance audits were completed to ensure the environment remained safe and well maintained.

Equipment was well maintained and suitable for people's needs. Regular safety checks and servicing were carried out to ensure equipment remained safe and effective to use. Staff demonstrated a good understanding of the safe use of equipment and were able to identify and report any faults promptly, helping to minimise risks and maintain people's safety.

Robust systems were also in place to respond to emergencies. Routine fire safety checks and evacuation drills were undertaken, and people were actively involved in fire safety planning. Each person had a detailed, person-centred Personal Emergency Evacuation Plan (PEEP) which reflected their individual needs and the support they would require in an emergency.

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.

Staff told us there were enough staff on duty to meet people's needs safely and provide care in an unhurried and responsive manner. Feedback from staff was positive, with one staff member saying, “The workload is manageable,” and another telling us, “Staffing levels are good.”

Staff received a combination of face-to-face and online training to ensure they had the knowledge and skills required to meet the needs of people living at Ashby Court Care Home. Training covered both mandatory and role-specific subjects and supported staff to provide safe, effective and person-centred care. Staff spoke positively about the training opportunities available.

There were sufficient numbers of suitably skilled and experiences staff deployed to meet people’s need safely. Rotas demonstrated planned staffing levels were maintained, and staff were allocated appropriately based on people’s assessed needs and dependency levels. Staff received regular supervision, providing opportunities to discuss their practice, performance and development needs. A relative told us, “The staff are good, there are always enough staff around.”

The provider operated robust recruitment procedures to help ensure suitable staff were employed. Pre-employment checks were completed before staff commenced work, including enhanced Disclosure and Barring Service (DBS) checks, references and verification of employment history where appropriate. These measures supported safer recruitment practices and helped reduce the risk of unsuitable individuals working with people using the service.

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 home was maintained to a high standard and supported effective infection prevention and control (IPC) practices. An experienced domestic team ensured cleaning was completed thoroughly, including regular deep cleaning of the environment. Staff followed robust IPC procedures, and the registered manager completed regular audits and checks to monitor standards and identify any areas for improvement.

People were supported in a clean, safe and hygienic environment that helped minimise the risk of infection. The home was clean, well maintained and free from unpleasant odours throughout most areas of the service during our visit. Relatives also spoke positively about cleanliness, with one relative commenting, “There's never any smell, they're very clean.”

Staff received training in infection prevention and control, including the safe use and disposal of personal protective equipment (PPE) and the actions required to protect people during an outbreak. Staff were observed wearing PPE appropriately when required and adequate PPE stock were maintained and readily available for staff to use. This helped ensure people were cared for in a safe environment and protected from the risk of infection.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Systems were in place to ensure medicines were ordered, received, stored, administered and disposed of safely and in accordance with current guidance. Only staff who had completed medicines training and been assessed as competent were authorised to administer medicines. Staff demonstrated a good understanding of the medicines people were prescribed, including their purpose and the correct method of administration. Medicines Administration Records (MARs) were completed accurately at the time medicines were given, providing a clear audit trail, supporting effective monitoring, and helping to ensure people received their medicines as prescribed.

Relatives spoke positively about communication regarding medicines and healthcare support. One relative told us, “[Name] was struggling with medication and they walked me through every step and kept me in the loop all the way.” This demonstrated staff worked collaboratively with relatives and ensured they remained informed about important decisions affecting their loved one's health and wellbeing.

Clear protocols were in place for the administration of PRN (as required) medicines. These outlined when PRN medicines should be offered, maximum dosage limits and when further medical advice should be sought, helping to ensure medicines were administered safely and consistently in response to people’s individual needs. However, we found one person's care plan did not fully align with their PRN protocol. This was raised with the management team during the inspection and immediate action was taken to review and amend the documentation, ensuring staff had consistent and up-to-date guidance to support safe medicines administration.

Where people required medicines to be administered covertly (by hiding the medicine in food or drink), appropriate assessments, best-interest decisions and supporting protocols were in place. Staff followed these protocols to ensure medicines were given safely, consistently and in line with agreed arrangements. This helped to meet people’s health needs while promoting their rights, dignity and wellbeing.