Ashfield House - Raunds

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.

This service scored 56 (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 ensure lessons were learned and improvements were made following safety incidents.

The service recorded and reviewed accidents and incidents each month. There was evidence that appropriate action was taken following some incidents, including safeguarding referrals, referrals to the falls team and the introduction of sensor equipment. There were also positive examples where action taken following incidents had improved outcomes for people.

However, incident reviews did not always demonstrate that repeated incidents were fully explored or that actions taken were evaluated for effectiveness. Records showed a pattern of repeated falls involving a small number of people, many of which were unwitnessed. Although the provider had taken action in response, there was limited evidence that measures introduced were consistently reviewed to establish whether they had reduced the risk of further falls.

Staff feedback about learning from incidents was mixed. Some staff told us learning was shared with them, while other staff members said they were sometimes unaware of what needed to change following incidents. Staff meeting records showed care practice issues and reminders were discussed. However, there was limited documented evidence showing how learning from specific incidents and investigations was consistently shared with the wider staff team. There was evidence that families were informed following incidents, including information about clinical outcomes. However, some relatives told us they did not always receive a clear outcome after being told an incident was being investigated.

Overall, the provider had systems to record and review incidents and took appropriate action in some cases. However, further improvement was needed to ensure learning was consistently identified, shared and used to reduce the risk of similar incidents happening again.

The provider worked with people and healthcare partners to maintain safe systems of care. There were processes in place to support safe admissions, transfers and ongoing care. People told us their needs were assessed when they started using the service, and information about their needs was gathered to help staff plan their care and support.

Hospital passports and treatment escalation plans were in place to support people when they moved between services. These contained information about people’s health conditions, medicines, abilities and support needs. Hospital packs were available on the electronic care system, and staff knew how to access this information quickly when needed, including in an emergency.

Overall, the provider had systems in place to support continuity and safe transitions between services.

The provider did not always take sufficient action to protect people from avoidable harm and manage known risks.

People and relatives generally told us they felt safe living at the service. The provider had recognised when they were having difficulty safely meeting some people’s needs and had raised concerns with the multidisciplinary team and local authority. This was positive.

However, while longer-term arrangements were being considered, immediate risks were not always managed effectively. For example, one person had recurrent falls and required supervision due to known risks. We observed them on several occasions in a communal area without staff present, where they appeared unsteady when mobilising. The person also required Level 1 fluids, which are slightly thickened drinks, to support them to swallow safely and reduce the risk of choking or aspiration. Records showed they had previously attempted to drink other people’s normal fluids. We observed them in communal areas where other people’s drinks were accessible, which placed them at risk of drinking fluids that were not suitable for their assessed needs. Although the provider had informed the local authority that they could no longer safely meet the person’s needs and an alternative placement was being sought, there was limited evidence that additional measures had been introduced to manage these risks in the meantime, or that the measures already in place were effective in keeping the person safe.

The provider had a safeguarding policy in place. Staff and managers had completed safeguarding training and understood how to recognise and report concerns. Safeguarding referrals were made to the appropriate agencies when required.Deprivation of Liberty Safeguards (DoLS) applications had been made where needed, and conditions attached to DoLS authorisations had been followed.

Overall, the provider understood their safeguarding responsibilities and raised concerns appropriately. However, they did not always take sufficient action to manage immediate risks while longer-term arrangements were being made.

The provider did not always work with people to manage risks in a way that was safe and reflected their individual needs and choices. Risk assessments were in place and staff generally understood people’s main risks. However, risk management plans did not always give staff clear and consistent guidance about how identified risks should be reduced. For example, one person had recurrent falls and had declined the use of a sensor mat. Their care plan contained measures to manage their falls risk and instructed staff to monitor their mobility. However, following their decision to decline sensory equipment, the plan did not clearly define the frequency or level of monitoring required.

Another person with recurrent falls had conflicting information in their records. One person’s assessment stated they required supervision when mobilising, while another stated they could mobilise independently using their Zimmer frame. During our assessment, we observed the person mobilising using different walking aids and appearing unsteady, without staff intervening. The records did not clearly explain when supervision was required or what staff should do if it could not be provided.

We found similar concerns in another person’s falls care plan, which contained conflicting instructions about when they required staff assistance and did not clearly define the level or frequency of monitoring needed.Records also did not always provide assurance that planned risk-management measures, including scheduled wellbeing checks, were completed at the required times.

Although staff had received relevant training, the concerns identified showed that staff did not always recognise or respond effectively to risks in practice. For example, we observed a person with known falls risks mobilising unsteadily without staff intervention. Care records did not always provide staff with clear and consistent guidance about when increased supervision or intervention was required. Management oversight had not identified or addressed these inconsistencies to ensure staff had the information and support needed to manage people’s risks safely.

Overall, risks were assessed, but risk management plans were not always clear, individualised or sufficiently detailed to help staff manage known risks safely while respecting people’s choices.

The provider did not always make sure risks within the care environment were effectively managed.

There were systems in place to monitor the safety of the premises and equipment. Regular environmental and safety checks were completed, maintenance support was available, and actions identified through safety assessments were followed up. The provider confirmed actions from fire safety, emergency lighting and water safety assessments had been completed.

However, we identified a potential risk from an open kitchenette in a first-floor communal area, which contained a kettle and toaster that people could freely access. Some people using this area were living with dementia and walked around the communal areas. We also observed occasions when staff were not present in the lounges. Risk assessments were in place for the appliances, but the control measures referred to staff supervision “where possible” and did not clearly explain how people would be kept safe when staff were not present. We were therefore not assured that the measures in place were sufficient to reduce the risk of people accessing appliances with hot surface temperatures and hot water without support.

Personal emergency evacuation plans (PEEPs) were in place and included information about people’s mobility, equipment and individual evacuation needs. However, staff needed to use these alongside separate documents showing fire zones and fire-door locations. Some PEEPs also contained limited instructions about the support people would need during an evacuation. This meant information needed in an emergency was not always clear and immediately accessible.

Overall, the provider had systems in place to maintain the safety of the environment. However, environmental risks were not always clearly assessed and effectively reduced.

The provider did not always make sure there were enough staff deployed in the right areas of the service to meet people’s needs safely.

Staff were safely recruited, completed mandatory training and received regular supervision and appraisals. Records showed catheter care training had been completed in 2023. Given some people required support with long-term catheters, the provider subsequently allocated refresher catheter care training to staff.

The provider used dependency tools to calculate staffing levels. However, staff were not always effectively deployed according to people’s risks and supervision needs. For example, on the first floor, staff were often based near the care station or one lounge, leaving another lounge without a constant staff presence, including where people had increased falls risks. Inspectors had to alert staff when people required support on a few occasions, to prevent falls.

People and relatives were generally positive about individual staff. However, some people told us staff did not always have time to sit and talk with them, and we observed periods of limited interaction. A relative told us, “I do see plenty of staff about, but they are all very busy.”Staff feedback about staffing was mixed. Some staff felt staffing was sufficient, while others said staff could be stretched, particularly when supporting people living with dementia who required increased supervision.The provider used staff from its other homes to cover shortages. These staff had completed the organisation’s general induction and received a verbal handover. However, there was no documented service-specific induction to show they had received information about people’s individual needs and risks. The provider acknowledged this and took action to address it.

Overall, staff were safely recruited, trained and supported, and systems were in place to calculate staffing levels. However, staffing and deployment did not always reflect people’s supervision needs and individual risks, particularly on the first floor. Following our assessment, the provider reviewed staffing arrangements and told us they had increased staffing levels in response to the concerns identified.

The provider did not always assess and manage the risk of infection effectively. Most areas of the service were clean, and the kitchen was clean and well organised. However, infection prevention and control practices (IPC) were not always consistently followed or monitored.

Some armchairs in a communal lounge were heavily stained, including with dried food and fluid stains. Although one chair was removed after we raised concerns, other stained furniture remained in use. We also found several drinking jugs with heavy staining and damaged internal surfaces, which meant they may not have been effectively cleaned. These were removed promptly when we raised the concern.

During our site assessment, we found some hand sanitiser dispensers were empty. We also found gaps in housekeeping and frequently touched-point cleaning records, and the deep-cleaning records for fabric chairs were not available. Although cleaning records were checked by management, these checks had not identified all the gaps we found.

We observed inconsistent IPC practice despite staff having completed relevant training. On one occasion, safe hand hygiene practices were not followed consistently. During mealtimes, we also observed staff wearing the same gloves while carrying out different food service tasks and when supporting different people, without changing gloves between tasks. This showed that learning from training was not always embedded in staff practice. Management oversight had not identified or addressed these practices. There was some improvement in this practice on the second day of our assessment.There was also good practice. The wider environment was generally clean. The kitchen was clean and organised, food was stored safely, and appropriate protective clothing was used.

Overall, the provider had IPC systems in place and most areas were clean. However, IPC practices were not always consistently followed or effectively monitored, and some infection risks had not been identified and addressed promptly.

The provider generally managed medicines safely, and people received their medicines as prescribed. People and relatives were positive about medicines support and told us medicines were given when needed.

Staff administering medicines had completed training and competency assessments. Medicines were stored securely and at appropriate temperatures. Protocols were in place for medicines prescribed to be taken when required, with records showing why these were given and whether they had been effective. Controlled drugs were managed safely, and medicines no longer required were returned appropriately.

However, we found some discrepancies between the physical stock of regular medicines and the balances recorded on the electronic medicines system. The provider needed to make sure stock records were accurate and that any differences were identified, investigated and corrected promptly.

Overall, people received their medicines as prescribed and medicines systems were generally working effectively. Some improvement was needed to ensure medicine stock records were consistently accurate.