Ashgale 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

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 meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulations in relation to safe care and treatment and safeguarding people from abuse and improper treatment. This was because the provider had not always assessed risks to people, in particular the risk of choking and they have not taken action to mitigate these risks in a timely manner. Medicines were also not always managed safely.

Where restrictions were in place on people’s liberty, there was no recorded evidence that the least restrictive options had been considered.

This service scored 50 (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 always have a proactive and positive culture of safety. Staff did not always investigate safety events and ensure lessons were learnt to continually identify and embed good practice.

The provider did not have a robust process in place to monitor or review incidents at the service. The provider had not analysed incidents effectively to understand any underlying trends and themes. This meant we could not be assured learning was taking place to help prevent similar incidents from happening again and that actions were being taken to mitigate future risks to people and staff. This meant they were not able to demonstrate how lessons were being learnt.

For example, whilst the provider reviewed accidents and incidents, where people showed distressed behaviours, there was no evidence that patterns or triggers were analysed to help understand and reduce these behaviours. Managers were not reviewing and reflecting on events within the service with their staff to reduce the risk of reoccurrence.

The provider did not always work well with healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety appropriately.

The service had not worked to ensure that one person’s care needs which had recently changed were fully reviewed and their recent health changes addressed. The registered manager had not adequately escalated their concerns, in a strong enough way to advocate for the person, and to ensure the necessary advice was sought so staff could care for the person safely. This left the person at risk of choking and social isolation because they were being cared for in bed unable to move to the communal areas of the home or to access the local community.

However, records evidenced people had been supported to access external health professionals appropriately and when needed.

The provider did not always work well with healthcare partners to ensure people’s safety and to protect them from the risk of neglect and poor care.

During the assessment one person with swallowing difficulties was placed at significant risk of choking due to the format of medicines that had been prescribed during a hospital stay. The registered manager had not immediately recognised the risks posed to the person in term of improper treatment as a result of a potentially unsafe discharge and had therefore not raised this as a safeguarding concern. This meant the provider was not always able to evidence how they ensured people were protected from the risk of improper treatment and that safeguarding concerns were dealt with appropriately to ensure people were kept safe.

Another person had recently been subject to more significant restrictions to ensure that all people who lived in the home felt safe. It was not clear that the manager had considered all of the options including those that were least restrictive , or that the decision to impose the restrictions had been made in the person’s best interest.

Staff completed training to understand about safeguarding and were able to describe how to recognise and report abuse. The manager discussed how to recognise and report abuse with staff.

The provider requested appropriate authorisations, as they are legally required to do, where people might have been deprived of their liberty because they did not have the mental capacity to consent to their care.

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.

Staff did not always follow best practice or guidance to keep people safe. Some people were at risk of choking when eating and drinking. They had been assessed as requiring supervision and support and guidance from specialists to help staff reduce risks. Staff did not ensure 1 person was seated correctly while eating, as per advice that had been received. This increased the risk of the person choking while being supported with eating and drinking. Guidance from a specialist stated, “[Person] should be as far upright as possible.” During a mealtime, we observed staff standing over the person rather than sitting next to the person to support them with eating. For another person, guidance from a specialist stated, “[Person] requires small spoonfuls of food.” We observed staff supporting the person with large spoonfuls of food. This significantly increases the risk of the person choking.

Staff supporting people to eat and drink also did not exclusively focus on the person they were supporting. They got up to support other people with tea, drinks, yoghurt while supporting others. These practices increased the risk of choking for the people being supported to eat and drink as staff were not consistently supervising people while they were eating and swallowing the meals.

Care plans did not always include information to ensure staff knew how to support people to manage risks associated with their medical conditions. For example, for one person with diabetes, the risk assessment was not clear about what blood sugar level was considered low or high so the appropriate actions could be taken, and staff knew when to contact healthcare professionals for support. It also stated that the dose of a medicine (insulin) should be adjusted but did not state to what this should be adjusted to and who were to give the medicine as the medicine was being administered by the district nurses who visited the home.

Notwithstanding the above we requested and received assurances that these concerns were acted upon, and referrals to relevant healthcare professionals were made after our visit by the manager to ensure risks to people were being appropriately assessed, managed and reviewed as required.

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 registered manager undertook regular checks of the environment. People and their relatives told us the environment people lived in was safe. We saw there were systems in place to ensure the environment and equipment were safe, such as fire safety equipment checks, electrical equipment checks, food safety and environmental checks.

There were not always enough staff deployed to meet people’s needs safely and effectively. Staff did not always have the appropriate skills to engage people to meet their social, emotional and health needs.

The registered manager explained they used a dependency tool to ensure adequate staffing was available. However, we observed staffing levels were not sufficient based on people’s needs.

We observed that support staff were also responsible for cooking and cleaning, which took them away from providing direct care to, and supporting people for periods of time. This meant that whilst staff prioritised the personal care and support to people, they spent their time on other non-caring duties and had less time engaging and interacting with people.

One person with multiple health and support needs spent most of their time in their bedroom. Staff checked on them hourly, but they appeared to be busy elsewhere and doing other tasks and did not engage socially or carry out some form of social activities with the person apart from supporting them with meals and with personal care. As they had significant mobility needs, this left the person at significant risk of social isolation and unsafe care. Their care plan said they enjoyed the company of others and activities like listening to music and watching TV in their room and hand massages. We did not observe music or a TV playing whilst visiting them in their room. Their care plan had not been updated to reflect their recent changes in needs and to include the regular activities they enjoyed.

There was evidence of robust recruitment procedures. All potential staff were required to complete an application form and attend an interview, so their knowledge, skills and values could be assessed. 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 two 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. There were systems in place to review staffing levels against people’s dependency, these were reviewed regularly and in line with people’s changing needs.

Notwithstanding the above staff had been trained to provide safe support to people. Staff training was up to date and covered topics such as Oliver Mc Gowan autism awareness and safeguarding. Staff told us they had regular training. A staff member said, “We do a lot of training and then update it regularly when its due.”

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 premises were clean and cleaning schedules were in place. This helped ensure the premises were routinely kept clean. Staff wore personal protective equipment when supporting people with personal care and had undertaken training on infection control. There was an infection control policy to help guide good practice in this area and the manager carried out infection control audits to ensure the appropriate infection control standards were met.

The provider did not ensure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

A person had been discharged from hospital 9 days prior to our visit and had 6 new medicines prescribed, 3 of which were in a tablet format. The person had swallowing difficulties and according to feedback from staff required a liquid formulation of medicines, but at the time of our visit to the home, no arrangements had been made for an appropriate risk assessment to be completed and for medicines to be made available in a liquid format where these were available and indicated. The registered manager had not ensured these medicines were safe for the person to swallow since their hospital discharge back to the home. This meant that the person was at risk of possible choking.

Some protocols were in place for medicines prescribed to some people to be administered on a ‘when required’ basis (PRN). However, these were not detailed and did not inform on the actions staff needed to take when administering these medicines. For example, what staff should do if the medicine did not work and who to call for advice. For a person who was prescribed Diazepam PRN, the protocol was not signed off by the GP or the registered manager. Another person was prescribed Laxido PRN and again the protocol was in place but not signed off to show the relevant healthcare professionals had been consulted. This meant that the provider did not follow their own medicine policy and procedure for the administration of PRN medicines.

The provider carried out medicines audits to ensure people had received their medicines as prescribed and systems to manage medicines were adhered to. However, these were not working effectively as they had not identified the concerns we found during our visit.

Staff received training on medicines and people were supported with their medicines by staff whose competency to administer medicines had been assessed.

Following out visit we discussed the concerns we found about medicines management with the manager and they said they would review the management of medicines and take action to address our concerns.