Ashfield Nursing 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 requires improvement. At this assessment the rating has changed to good.

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.

The provider maintained clear records of accidents and incidents. We saw the registered manager regularly reviewed these to identify any themes or trends. Where areas of concern or examples of good practice were identified, these were shared with the wider staff team and the providers other location to support learning. Staff we spoke with identified an example: “When a new resident moved into the service, we worked closely with them, their family, and relevant professionals to understand their needs and preferences. We kept clear records, communicated effectively, and reviewed how they were settling in. This helped us adapt support, improve information sharing, and ensure the resident felt safe, comfortable, and well supported in their new home.”

This approach demonstrated a culture of continuous learning and improvement. It helped to strengthen practice and ensured people were supported in a way that promoted their ongoing safety and wellbeing.

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.

The management team completed thorough assessments for people referred to the service. These were carried out in partnership with the person, their relatives, current care provider and relevant professionals. This collaborative approach ensured the service was able to meet the person’s needs effectively. The management team also carefully considered compatibility with people already living at the service, which helped to ensure people could live together safely and reduce the risk of conflict.

This meant risk assessments and health information were shared before admission, ensuring staff understood the person’s needs from day one. The service maintained regular communication with healthcare partners and relatives during the transition, helping to ensure continuity of care.

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.

The provider worked in line with the Mental Capacity Act 2005 (MCA). The MCA provides a legal framework to support people who may lack the capacity to make specific decisions for themselves and promotes people being supported to make their own decisions wherever possible. Where people were unable to do so, decisions were made in their best interests and in the least restrictive way.

Mental capacity assessments were completed consistently and reflected people’s current needs. We saw the management team responded appropriately where needs had changed, for example by updating a person’s care plan in relation to covert medicines to ensure decisions remained lawful, clearly recorded and in the person’s best interests.

Where people required restrictions to keep them safe, the provider ensured appropriate applications for Deprivation of Liberty Safeguards (DoLS) were made to the relevant local authority. This helped to ensure people’s liberty was only restricted when necessary and legally authorised.

Staff had access to safeguarding and MCA policies and demonstrated a good understanding of their responsibilities. This supported them to protect people while also respecting their rights. A staff member gave an example of protecting a person’s rights by supporting them to make their own choices about daily routines. The person was given information in a way they could understand and was supported to express their wishes. As a result, their choices were respected, promoted independence, dignity and person-centred care.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People were supported to take part in activities that were important to them, including family visits and going on outings locally. These were appropriately risk assessed to ensure people could participate safely. For individuals with limited verbal communication, care plans clearly detailed their preferred communication methods. This helped staff to provide information in a way people could understand and supported them to make informed choices.

We saw examples of positive outcomes for people. For example, one person living with a breathing disorder received consistent and effective support. This included monitoring their respiratory health, support with prescribed inhalers and medication, and guidance to help manage their condition safely. Staff also worked with relevant healthcare professionals to respond to any changes in their health. As a result, the person's symptoms were better managed, reducing the risk of exacerbations and supporting their overall wellbeing.

Risks to people’s health and wellbeing were clearly assessed, with appropriate measures in place to minimise harm. This supported people to remain safe, promoted their independence and enabled them to do the things they enjoyed.

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.

Staff demonstrated an awareness of safety within the environment and generally took action to reduce risks. However, we identified some areas where further improvements were needed. For example, we observed a clinical waste bin that was unlocked and contained compacted waste that had not been emptied effectively. We also identified that the service was not recording lint removal in the laundry room. The service immediately rectified these concerns and put actions in place to ensure there was no likelihood of any reoccurrence. Other smaller areas of concern that required action had already been identified and were completed during our assessment.

Overall, there were monitoring systems in place to check the safety of the environment. Where concerns were identified, action was taken to minimise risks and help keep people safe.

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 reviewed documentation which showed staff received regular supervision to support their performance and development, which staff also confirmed. Staff completed a structured induction and had opportunities to shadow experienced colleagues, helping them to build confidence and competence in their roles. Training was provided to ensure staff had the appropriate skills and knowledge to support people safely and effectively.

Staff completed relevant training for their role, which meant people were supported by staff who had the skills needed to meet their individual needs and help them work towards their aspirations and fulfil their potential.

Staff told us they felt well supported and were encouraged to develop their skills and knowledge.

One family member said, “Staff are trained and know my loved one really well. They can recognise when something is not right and take action early to prevent situations from getting worse.”

Another family member told us, “I have sometimes had concerns about staffing levels, but staff work well together, seem well organised and always know what needs to be done.”

Residents provided mixed feedback about staffing levels. While some told us staff were available when needed and felt staffing had improved in recent months, others said they occasionally experienced delays in receiving support during busier periods. Overall, people felt staff worked hard to meet their needs.

The provider followed safe recruitment practices and had a supporting policy in place to ensure staff recruited were suitable to the role. The provider had actively recruited staff and continued to review staffing to increase the permanent nursing team. To support with continuity regular agency staff were used across all 3 of the providers services.

The combination of processes and staff training and support ensured appropriate staff were employed to support people safely.

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 generally clean, staff followed infection, prevention and control practices, and appropriate action was taken to reduce the risk of infection spreading. Concerns were identified promptly and shared with relevant healthcare professionals and agencies when required. People, relatives and visitors did not raise any significant concerns about infection control arrangements.

The registered manager took prompt action to address any issues and completed a full review of all areas within the home 3 times a day.

The provider had an up-to-date infection, prevention and control policy to guide staff practice. Staff had access to personal protective equipment (PPE) and were observed using this in line with infection, prevention and control (IPC) guidance. Staff supported people with their personal hygiene needs, and we observed people wearing clean clothes.

The service were aware of improvements required to ensure infection, prevention and control practices were consistently followed and that the environment was maintained to a standard that effectively protected people from harm. There was a comprehensive process in place for ongoing maintenance.

The service made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff had taken action to address medicines supply issues by reviewing medicines supplies and working with GP services to improve prescribing and medicines reviews. Staff managed medicines ordering, storage and disposal appropriately, maintained accurate stock balances and managed controlled drugs safely. Staff demonstrated learning from medicines incidents and took action to reduce the risk of recurrence.

Staff administered medicines safely and had systems in place to monitor administration and stock management. Care plans, PRN (when required) protocols and covert medicines (Covert medicines are medicines hidden in food or drink and given to someone who cannot make their own decision about taking them were managed well.

Staff completed medicines audits, monitored high-risk medicines and used communication and handover processes to support safe medicines management. The service demonstrated a positive approach to identifying and addressing medicines-related concerns.

Fridge temperature monitoring records were not always completed accurately and MARs, (medicine administration records) did not consistently record when medicines were administered late. This was addressed with the provider during the assessment and will be further strengthened with the provider moving over to electronic MARs as planned. The service was also working to address ongoing medicines supply issues and improve medicines-related documentation identified during the inspection.