Asher 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 – this means we looked for evidence that people were protected from abuse and avoidable harm.

This is the first assessment for this service. This key question has been rated 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. Systems were in place to investigate incidents, accidents and safeguarding concerns. These were routinely discussed at daily and regional meetings, to identify themes and ensure action was taken to reduce risks and used to drive improvement. Lessons were learnt to continually identify and embed good practice including sharing security alerts across the organisation to learn from safety events and increase staff awareness of potential risks to people’s safety.

All staff spoken with told us they were confident to raise concerns about safety and confirmed systems were in place to learn from incidents. Comments included, “We can discuss incidents at multi-disciplinary team (MDT) meetings. If we need to, we can modify and adjust peoples care plans,” and “De-briefing sessions take place post-incidents to look at what worked well, and what needed to be done differently in the future to minimise people’s anxiety.” Records showed learning from incidents was shared with staff through team meetings, supervision, handovers and reflective sessions. For example, a reflective session was used where a medication error had occurred to establish and analyse what happened, share feelings, and learn for the future.
 

The registered manager worked effectively with people, relatives and healthcare professionals to establish and maintain safe systems of care. They had consulted with people, relatives, professionals and staff when considering referrals to the service to ensure people's needs could be met safely before admissions were agreed. Since January 2025, 6 people had been admitted to Asher House. Five admissions had been successful, demonstrating that people's safety, wellbeing and continuity of care were maintained throughout their care journeys. Although 1 placement was not sustained, the registered manager and a registered nurse remained actively involved in discussions with relevant professionals to support the persons transfer to an alternative placement. This helped ensure continuity of care and support during the person's transition between services. The registered manager told us, “We are proud of the strong foundations we have built in a short period of time. Our core commitment is to empower people who have previously struggled to find stability in other settings. Many of the individuals we support have experienced multiple placement breakdowns, high levels of distress and significant barriers to engagement. Our focus is on creating a home-like environment where safety, trust and emotional security are prioritised from the outset.”

The registered manager and staff worked collaboratively with people and healthcare professionals to understand what being safe meant to each person and how best to achieve this. They demonstrated a clear understanding of safeguarding systems, processes and practices and ensured appropriate action was taken to protect people from abuse. Staff told us they felt able to raise safety concerns and were confident these would be acted upon appropriately. Records showed, concerns were recognised and reported promptly. Appropriate safeguarding referrals had been made to the local authority and notifications submitted to CQC in a timely manner when people had experienced abuse or were at risk of abuse. Daily meetings records, staff meeting minutes and supervision records reflected learning from safeguarding concerns were shared and acted on. This helped to ensure concerns were managed effectively and people remained protected from harm.

Staff focused on improving people’s lives while protecting their right to live safely and free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Staff had completed safeguarding training and demonstrated a strong understanding of the signs that may indicate a person was experiencing abuse. Examples provided included, “Self-neglect, or if they don’t want to interact with a particular person,” and, “Physical signs such as bruising or injury.”

The registered manager demonstrated a good understanding of the Deprivation of Liberty Safeguards (DoLS). Following changes in legislation introduced after the UK Supreme Court ruling on 2 June 2026, the organisation's regional medical director reviewed all people receiving care under the revised DoLS framework to determine whether existing authorisations remained necessary. Of the 5 people assessed, 1 was identified as no longer requiring a DoLS authorisation, as they had capacity to consent to their care and accommodation arrangements, which had previously been subject to restrictions under the DoLS framework.

The registered manager and staff knew people well and understood how to meet their needs safely and supportively. Risks were managed holistically, with a clear ethos of positive risk-taking rather than risk avoidance. Staff took a balanced and proportionate approach to managing risk, recognising that some restrictions were necessary to protect people and the wider public. Where restrictions were in place, these had been assessed as the least restrictive option. Restrictive practices were regularly monitored and reviewed, with action taken to reduce or remove restrictions wherever possible. For example, regular 'reducing restrictive interventions' meetings were held with people and staff. Restrictive practice data was analysed at daily and regional meetings to identify themes, trends and opportunities to further reduce restrictive practices.

People were involved in decisions about their care, including how risks to their safety were managed. Risk assessments contained detailed information about identified risks, and the actions staff should take to keep people safe and minimise harm during day-to-day activities and when accessing the community. Assessments were reviewed regularly to ensure they remained current and relevant. This enabled staff to support and empower people to take positive risks, respecting their choices while helping them engage safely in activities that mattered to them.

Staff demonstrated a good understanding of how people communicated their needs, emotions and distress. They understood the factors that could trigger distress and consistently followed the guidance outlined in people’s positive behaviour support (PBS) plans and PBS grab sheets. These documents contained clear and detailed strategies to ensure people received consistent support and behaviours of distress were managed positively in ways that protected people's rights and dignity. The registered manager and staff were clear that restraint was only ever used as a last resort. A restrictive practice register was maintained to record any interventions that restricted people's liberty or other rights. Records showed there had been 14 incidents where approved low-level prevention and management of violence and aggression (PMVA) techniques had been used. Documentation showed these interventions were used lawfully, proportionately and only for the legitimate purpose of protecting the safety of the person concerned and others around them.
 

Systems were in place to support the safety and maintenance of the premises, with required legionella, fire safety, electrical systems and equipment checks undertaken. However, arrangements for recording and monitoring these checks required further strengthening. Records and risk assessments were not consistently held at the service, making it difficult to demonstrate that identified actions had been completed. Fire safety checks were documented across multiple records, limiting effective oversight of their consistency. The registered manager responded proactively to these findings and confirmed that all health and safety records were being transferred to a digital system to improve accessibility, oversight and ongoing monitoring.

Regular fire drills were carried out, and 2 trained fire marshals were allocated to each shift. Staff demonstrated a good understanding of fire safety procedures and knew how to respond in an emergency. One staff member told us, “I have been involved in 1 fire drill this year; the feedback was that we responded well.” People’s, and where relevant staff members’, protected characteristics and individual needs had been considered within Personal Emergency Evacuation Plans (PEEPs). These plans provided clear guidance to ensure they could be safely evacuated from the building in the event of an emergency.

The provider had made appropriate adaptations to the environment to support people’s safety, independence and wellbeing. The premises were clean, well maintained and free from avoidable hazards. People lived in their own self-contained apartments, which had been designed around their individual needs following discussions with them, their families and staff. Apartments were personalised, spacious and included an en-suite bathroom, bedroom, lounge and kitchenette dining area. Furniture, which looked modern in design including heavy chairs and tables which could not be thrown had been provided to reduce the risk of injury. People were supported to stay safe in an environment that met their needs. For example, a smoking safety and fire risk management plan had been implemented to support a person to continue smoking, which had included a designated area and use of a fire-retardant smoking apron for their protection.
 

The provider ensured there were enough qualified, skilled and experienced staff to meet people's needs. Staffing levels and staff competencies matched the needs of people using the service, including the provision of 1-to-1 and 2-to-1 staff support which helped ensure they received consistent, safe and good-quality care. Staffing levels were reviewed daily and adjusted in response to changes in people's needs ensuring there were sufficient staff available to keep them safe and support them to participate in activities of their choosing, when they wanted to. Staff told us there were enough staff available to meet people's needs. They were aware recruitment was ongoing to fill vacant posts. One member of staff told us, "Even if we're 1 or 2 staff short, we are still adequately staffed, and the manager will always help out."

The provider followed safe recruitment practices. Recruitment records confirmed all required pre-employment checks were completed before staff started work and that staff had the appropriate skills and experience for their roles. Staff completed training relevant to their responsibilities and told us they were encouraged to develop new skills and progress their careers. One staff member described the training as “interesting and helpful in understanding how to support autistic people and the importance of routines.” Staff also completed a comprehensive induction and received ongoing support through regular individual and group supervision. However, a review of supervision records identified the need for greater consistency. Although line managers met regularly with staff, records showed variations in the supervision experience across the workforce and did not always clearly document agreed actions to support development and professional progression. In response to this feedback, the registered manager had sourced a new supervision format and was implementing it across the staff team.

The provider had effective systems in place to assess and manage infection prevention and control (IPC) risks in line with current national guidance. This helped ensure people lived in a clean, safe and hygienic environment, reducing the risk of infection. The service was clean, tidy and well maintained, with effective arrangements in place to promote cleanliness and hygiene throughout. To ensure standards were maintained during a housekeeper vacancy, an additional member of care staff was rostered to support cleaning duties and ensure the environment and equipment remained clean. A member of staff told us, “All the furniture is wiped down and every morning we wipe all the frequent touch points, such as light switches. Nurses and healthcare assistants all help with the cleaning.”

Information relating to IPC was readily available throughout the service and was appropriately shared with staff, people using the service and visitors. Robust daily and weekly cleaning schedules were completed, demonstrating regular monitoring of cleanliness standards. Cleaning equipment, including mops, was colour coded, cleaned and stored appropriately to minimise the risk of cross-contamination. The provider carried out regular IPC audits to monitor compliance and identify any areas for improvement. Staff had received training in IPC and food hygiene and demonstrated a clear understanding of their responsibilities. During the inspection, we observed staff following good hand hygiene practices and using Personal Protective Equipment (PPE) appropriately. Food was stored safely, and staff followed safe procedures when preparing and handling food. The service had recently achieved a food hygiene rating of 5 from the local environmental health authority, reflecting the highest standard of food hygiene compliance.

Systems were in place to ensure medicines were managed safely and met people's needs, capacities and preferences. People received support from staff who followed robust processes for the administration, recording and storage of medicines. All medicines within the service were administered by nursing staff. Good practice was observed in the management of medicines liable to misuse, including diazepam and zopiclone, with administration appropriately countersigned. Nurses' competency to administer medicines was assessed annually to ensure safe practice. Where medicines were administered covertly (disguised in food or drink), this had been assessed and authorised in line with the Mental Capacity Act 2005. A nurse told us, "It has to be in the person's best interests and would have been decided at a multi-disciplinary team meeting." Another nurse explained that pharmacists were consulted regarding the safety and suitability of crushing medicines before they were administered covertly.

A review of medication records demonstrated information about people's medicines was accurate, up to date and regularly reviewed. Stock checks were accurate and corresponded with administration records, providing assurance that people received their medicines as prescribed. Where medicines were prescribed on a "when required" (PRN) basis, clear and personalised protocols were in place. These protocols provided staff with detailed guidance on when and how to administer medicines safely, including support for people experiencing pain, distress or anxiety, and where medicines were administered covertly. The service demonstrated an awareness of, and commitment to, the stopping over medication of people with a learning disability and autistic people (STOMP) programme. Staff worked proactively with people, GPs and other healthcare professionals to review psychotropic medicines and reduce the risk of inappropriate prescribing in line with this NHS England initiative.