Ashleigh Manor Residential 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 inadequate. At this assessment, the rating has remained inadequate. This meant people were not safe and were at risk of avoidable harm.

The provider was previously in breach of the legal regulation in relation to safe care and treatment, safeguarding, person-centred care, dignity, staffing and good governance. Improvements were not found at this assessment, and the provider remained in breach of these regulations.

This service scored 34 (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.

At the last assessment, we found the provider had failed to effectively operate systems to identify, assess and mitigate risks associated with the health, safety and welfare of people using the service. At this assessment, we found some improvements had been made. Systems to review incidents and feedback were in place, and the provider had introduced new audits and monitoring processes. However, these systems had not identified the concerns found at this assessment and could not be relied upon to support learning and improvement.

Staff described a supportive team culture and an open-door approach from managers, and some staff felt listened to when raising concerns. However, records showed incidents and risks were not always analysed effectively, and learning was not consistently embedded into practice. For example, accidents, medicines errors and quality issues identified during this assessment had not been identified through internal audits or used to drive improvement.

Risks relating to care planning, medicines and fire safety had been identified at previous assessments but continued at this assessment, demonstrating lessons had not been fully learned or sustained. This contributed to a breach of regulation in relation to safe care and treatment, safeguarding, person-centred care, dignity and governance.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

At the last assessment, the provider did not have robust assessment processes to ensure a safe and smooth transition between services to reduce the risk of avoidable harm to people. At this assessment, improvements had not been made.

People were exposed to avoidable risks because pre-admission assessments and care planning processes were not always accurate or complete. We found examples where people’s care needs were not fully assessed or reflected in their care plans. For example, one person’s hospital discharge assessment identified significant risks including falls, self-neglect and nutritional needs, but this information had not been included in the provider’s assessment or care plan. Care records were often incomplete, inconsistent or contained conflicting information, which meant staff did not always have clear guidance on how to meet people’s needs safely.

Transitions within the service and changes in people’s needs were not always managed safely. For example, people had been moved rooms without appropriate assessment or consent processes, and care plans were not always updated following changes in a person’s health or risk. This contributed to a breach of regulation in relation to safe care and treatment, person-centred care, need for consent and good governance.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

At the last assessment, we found systems and processes had not been established or operated effectively to investigate allegations of abuse, and some people were subject to restrictive practices without a legal framework in place to support them. At this assessment, we found improvements were still needed.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). In care homes and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS).

We found ongoing concerns relating to the understanding and application of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS) process. Some people were subject to restrictions without appropriate legal safeguards in place. For example, restrictions on visits and changes of rooms were implemented without evidence of capacity assessments or best interest decision-making. In addition, we found people continued to receive medicines covertly without appropriate consent processes or a legal framework in place to support these decisions.

Senior staff demonstrated they understood their roles and responsibilities under the MCA, as well as the importance of protecting people’s human rights; however, we found this was not consistently reflected in their practice.

The continued failure to provide care and support in line with the Deprivation of Liberty Safeguards code of practice contributed to a breach in regulation in relation to safeguarding, person-centred care, the need for consent and good governance.

Some staff had received training in safeguarding adults. They were aware of their responsibilities and knew what action to take should they suspect a person’s safety or welfare was at risk. However, staff did not always escalate their concerns to external agencies in line with the providers’ policy and their training. Furthermore, we noted 12 staff had not completed safeguarding adults training. This placed people at risk of harm as they were supported by staff who may not identify, report, record, or act on suspected abuse appropriately.

Although improvements had been made and there were processes to liaise with local safeguarding partners, these were not always supported by thorough internal assessment or documentation. These concerns contributed to a continued breach in safeguarding and good governance.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

At the last assessment, we found the provider’s failure to ensure risks relating to the safety of people receiving care and treatment were appropriately assessed, mitigated, or effectively managed had placed people at an increased risk of avoidable harm. At this assessment, we found most people had a range of risk assessments in place. However, these were largely generic, not person-centred or reflective of the actual risks associated with people’s care and support needs. For example, one person had risk assessments which identified risks associated with eating and drinking, including weight loss, choking, and malnutrition; however, their care plan stated they were fully independent, enjoyed a normal diet, and had no identified swallowing concerns.

The provider’s ongoing failure to take adequate steps to address concerns relating to the management and mitigation of risks meant people continued to be exposed to the risk of avoidable harm. For example, we found insufficient action had been taken to manage and reduce known risks relating to falls, weight loss, skin integrity, epilepsy, and the use of equipment.

Care plans and risk assessments throughout the service were not always accurate or up to date and lacked sufficient guidance about how to manage or mitigate risks, which potentially placed people at risk of harm. For example, one person had been diagnosed with Epilepsy. There was no care plan or risk assessment in place to support staff in delivering effective epilepsy care.

While some incidents were reported and reviewed, care records were not consistently updated to reflect the outcomes of these incidents or the action taken to reduce the risk of recurrence and protect people from harm. Staff had not been provided with any written guidance on how they should manage or mitigate these risks. Care staff told us during feedback they did not necessarily read people’s care plans. Senior staff told us there was no system where care staff were updated or alerted when changes in people’s care plans had taken place.

People’s involvement in the development of their care and support varied according to their individual needs and preferences. However, care records showed limited evidence people were consistently involved in developing or reviewing their care plans. Documentation did not always evidence people’s wishes, and consent processes were unclear or not followed. Opportunities for people to express preferences were observed in day-to-day care, such as choice of meals and activities, and staff were seen supporting people in a respectful way. However, this was not consistently reflected in formal care planning and risk management processes.

Some relatives told us communication had improved, and they were now more involved in decisions about care and support. One relative said, “They invite me in to discuss and make all decisions with any care plan changes.” However, others told us they had not seen care plans or risk assessments and were not always involved in reviews.

The provider’s continued failure to ensure risks relating to the safety of people receiving care and treatment were appropriately assessed, mitigated, or effectively managed placed people at an increased risk of avoidable harm. This contributed to breaches of regulation in relation to safe care and treatment, person-centred care, and good governance.

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. At the last assessment, we found the failure to ensure people were protected from risks associated with their living environment placed them at an increased risk of harm. At this assessment, whilst some improvements had been made, people remained at risk.

The provider did not ensure a consistently safe environment, and significant risks identified at the previous assessment remained unaddressed. For example, the previous assessment highlighted serious concerns regarding fire safety arrangements. At this assessment, we found multiple ongoing fire safety issues, including fire doors being wedged open, blocked fire exits, and insufficient evidence fire alarms and emergency lighting were being tested regularly. The providers on going failure to address fire safety concerns placed people, staff and visitors at increased risk of avoidable harm in the event of an emergency.

The provider had not ensured effective systems and monitoring arrangements were in place to prevent water temperatures exceeding 44°C. Routine water temperature checks identified temperatures above this threshold in several locations throughout the home; however, there was no evidence timely or appropriate action had been taken to address these findings and mitigate the risk of scalding. The provider had not implemented adequate control measures or guidance to manage this risk. As a result, people were exposed to an ongoing and avoidable risk of harm from scalding.

The provider’s ongoing failure to identify and act on environmental safety concerns placed people, staff and visitors at an increased risk of avoidable harm. This contributed to breaches of regulation in relation to safe care and treatment, and good governance.

The provider had invested in the service and taken action to address some of the environmental concerns identified at the previous assessment. For example, there was a clear programme of maintenance and redecoration. Several corridors and communal areas had been repainted, which improved the overall environment for people. The kitchen had also been refurbished, and areas of the service previously affected by an unpleasant odour were no longer present.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs. At the last assessment we found the provider’s failure to deploy enough skilled staff to meet people's assessed needs and ensure staff received the support, training, and professional development necessary for them to carry out their roles and responsibilities, placed people and staff at an increased risk of avoidable harm. At this assessment, we found improvements were still needed.

Staffing levels were not always sufficient to ensure people’s needs were met promptly, particularly during night shifts, and staff reported feeling stretched. Relatives also told us staff often appeared busy, and people in communal areas were not always supervised or supported in a timely manner.

We were not assured the deployment of 4 staff members overnight was sufficient to meet people’s assessed needs or to ensure their safety in the event of an emergency. This shortfall increased the risk people may not receive timely support during urgent situations, such as a fire or medical emergency, potentially compromising their safety and wellbeing.

There were gaps in staff training and inconsistencies in induction and supervision processes. Records showed several staff had not completed mandatory training, and induction documentation was incomplete. This meant the provider could not be assured staff had received the necessary training, support, and oversight to carry out their roles safely and effectively. The ongoing failure to deploy enough skilled staff to meet people's assessed needs contributed to a breach of regulation in relation to staffing, safe care and treatment, and good governance.

We did not identify any concerns with the provider’s recruitment processes. Records confirmed a range of checks, including application, interview, and Disclosure and Barring Service (DBS) checks, were conducted before staff started working at the service. DBS checks provide information, including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

The service did not always manage infection prevention and control risks effectively, although improvements had been made since the last assessment.

We identified concerns with laundry processes, where soiled items were not always managed in a way that minimised the risk of cross-contamination. We discussed our findings with the housekeeping staff and the provider, who took immediate action to address these concerns. We also found some staff did not consistently use appropriate personal protective equipment (PPE), and infection prevention and control (IPC) training had not been completed by all staff.

However, improvements had been made, including action taken to address laundry practices and a reduction in unpleasant odours in the service. Throughout the assessment, we saw cleaners were constantly busy, and there were cleaning structures in place which covered all aspects of the service overseen by a housekeeper. Relatives told us they were satisfied with infection control measures when people were unwell.

The provider did not make sure medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

At the last assessment, we found the provider failed to store and manage people’s medicines safely and maintain accurate records relating to the management of people’s medicines. At this assessment, we found while some improvements had been made, further improvements were needed.

The provider did not ensure medicines were always managed safely. We found multiple concerns with medicines management. Medicines were not always stored securely, with cabinets left unlocked and accessible to others. Records were not consistently completed, with gaps in administration charts and instances where medicines were signed as given but remained in packaging.

Some medicines were administered outside safe guidelines, including a controlled drug being used past its expiry date and emergency medicines without clear protocols or staff understanding of how to use them.

‘When required’ medicines now had person-centred protocols in place to guide staff as to when these might be needed. However, we found one ‘rescue’ medicine for seizures, with no detailed instructions or care plan available. Staff were unsure of when or how it should be given, or who by. This led to risks of ineffective and unsafe management if a seizure should occur. We fed back this concern, and staff told us they would contact the GP surgery to get clear instructions and a medicines review for this person.

Medicines were not always given as prescribed, and people’s medicines administration records were not always well completed. There were some gaps in records where it was not possible to tell whether doses had been given. In some other cases, doses remained in the blister packs, although they had been signed as given on people’s charts. When some medicines were prescribed multiple times a day, the times were not always recorded so it was not possible to tell whether safe time gaps were left between doses. From the records we checked, it was not possible to be assured people always received their medicines safely and correctly.

Improvements were needed in the management of covert medicines administration. Records did not consistently demonstrate mental capacity assessments and best interest decisions had been completed appropriately. Some medicines appeared to be administered covertly despite not being included on the authorised covert administration list.

Medicines policies were in place to guide staff; however, these were not always being followed. Regular medicines audits were being completed. However, they had not identified the issues with medicines we found.

There had been some improvements, such as better recording of creams and appropriate management of patches. However, these improvements were not sufficient to ensure safe practice overall, and audit systems had not identified the issues found. The continued failure to store and manage people’s medicines safely and to keep accurate records relating to the management of people’s medicines contributed to a breach of regulation relating to safe care and treatment, person-centred care, the need for consent and good governance.