Ashbury Lodge Residential 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 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 regulation in relation to people’s safe care and treatment.

This service scored 59 (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 based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. Incidents, such as altercations between people using the service, and falls occurred regularly. Although there was a process to review and analyse falls, there was no process to review incidents where there were altercations between people. This did not enable any trends and themes to be identified. This meant lessons could not be learnt to improve practice. Additionally, we found safeguarding incidents had not always been referred to the local authority safeguarding team where appropriate, in line with their legal duties. However, we saw some incidents were discussed in daily meetings with staff to improve practice. Staff felt there was a good learning culture at the service. There was evidence of daily meetings at the service, whereby all collaborative involvement and changes to care approach were communicated to the team effectively.

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 had documents in place to support safe transitions into hospital, which included information about any known risks and people’s preferences.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always share concerns quickly and appropriately. For example, incidents involving physical abuse between people using the service had not always been referred to the local authority safeguarding team. This meant people were not fully safeguarded and put people at risk of abuse. However, staff had received training and could describe different types of abuse. People and their relatives told us people were safe. One relative commented, “When I go to visit and I visit a lot, I’ve never had any safety concerns.”

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. During our site visit, we observed a mattress being used as a crash mat for one person, and a serving table was placed on top of this. The table was used for serving hot food and drinks. and was unstable. This meant there was a health and safety risk to the person. There was also a risk of the person falling from the bed and rolling off the mattress which put the person at risk of injury. The manager explained this was a temporary measure whilst they were waiting for a more suitable crash mat.

Additionally, one person who was at risk of developing urinary tract infections (UTI), was not consistently being supported in line with their care and support plan in relation to encouraging fluids and continence support. We saw evidence this person had developed a UTI after a period of 11 days, when their care and support plan had not been followed. This meant the person’s known risks had not been managed effectively.

However, other people’s care plans to manage risks were being followed. Relatives told us they felt people’s risks were well managed and raised no safety concerns.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. During our site visit, we observed there were visible gaps at the bottom of 5 fire doors, which put people at risk of fire. These had not been identified by the service, nor by the service’s fire risk assessment which had been completed by an external service. We raised these concerns with the local fire service.

During the site visit, we observed a number of health and safety concerns, such as trailing wires in a person’s bedroom, and an emergency light cord which appeared to have been cut and was left loosely in the bathroom. This was a risk to people living with dementia.

Other health and safety checks took place regularly, such as gas safety, legionella, and equipment checks. Fire drills took place regularly to ensure staff were competent in the event of a fire. Following the conversations with the fire service, leaders confirmed plans were in place to address the gaps in the fire doors.

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 had been recruited safely and received training appropriate to their role. Staff told us they felt supported by leaders. During our site visit, there were enough staff to meet people’s needs. All relatives told us there were enough staff available. Comments included, “There is sufficient staff, there are carers and a senior lady in the office, if they are a bit short staffed the lady in the office will come to their aid”, and “Yes in the main, there are always staff about”. Staff raised no concerns about the staffing levels at the service and staff rotas confirmed that staff were deployed in line with the service’s assessed safe staffing levels.

The provider did not always assess or manage the risk of infection. During our site visit, we observed various infection prevention and control (IPC) concerns. These included unclean communal bathrooms, chipped paintwork in communal areas which meant these areas could not be cleaned effectively, and some equipment which was visibly dirty. There were also odours of urine in some communal bathrooms.

Audits had not identified all of the above concerns. Additionally, some staff told us they felt cleaning processes needed improving. One staff member told us, “It’s not up to my level, honestly.” We raised this with leaders who had implemented new and improved cleaning processes, and staff also confirmed this. People and relatives told us they felt the service was clean and raised no concerns.

Medicines were stored safely. Staff were knowledgeable about medicine administration processes and there were processes in place to regularly check staff’s competence in administering medicines. There was a policy which clearly outlined procedures. The service had systems in place for safe medicines management and demonstrated structured processes. People receiving medicines covertly were having their medicines managed in line with Mental Capacity Act (MCA) principles. Relevant documentation such as best interest decisions and risk assessments were present and reviewed regularly.

However, one person did not have a risk assessment in place for flammable topical creams, which put people at risk of fire. Despite this, we were told this risk was being managed by the provider, such as ensuring smoking took place away from other people. Other people had the appropriate risk assessments in place. The missing risk assessment was put in place during the inspection.

Stock checks had not always been completed for medicines which required additional and specific storage, to ensure these were being administered safely, in line with the service’s policy. Additionally, where people declined their medicines, we did not always see evidence that staff had re-attempted to administer them. However, leaders told us staff sought medical advise if people refused their medicines.