Ashdale

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 remained good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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.

Accidents, incidents, and complaints were thoroughly investigated, and appropriate actions were taken to drive improvement. This included reviewing care plans, risk assessments, and internal processes, as well as providing additional staff training where necessary. Any concerns regarding unexplained bruising were investigated and reported to the local authority.

Evidence showed discussions took place during staff meetings to support learning and enhance practice. The provider also disseminated information across the organisation to support continuous improvement and shared learning. Throughout the assessment process, the provider demonstrated openness and transparency.

Relatives confirmed they were kept informed when issues occurred and were given opportunities to contribute their views on how problems could be addressed. Staff reported they were encouraged to develop their skills and knowledge and were supported in accessing further learning and development opportunities to enhance safety in the service.

The provider collaborated with individuals and healthcare partners to establish and maintain robust systems of care, ensuring safety was consistently monitored and effectively managed. They ensured continuity of care was maintained, particularly during transitions between different services. A relative said, “We all worked together and it was a positive outcome”.

Staff demonstrated a clear understanding of the procedures to follow when people moved between services, such as hospital admissions or discharges and general medical appointments. They confirmed individuals had hospital passports containing detailed information about their health and communication needs. This documentation facilitated timely and accurate information sharing with emergency personnel, thereby supporting appropriate and personalised care.

The provider collaborated with people and healthcare partners to understand what safety meant to them and the most effective ways to achieve it. Staff focused on enhancing individuals’ quality of life while safeguarding their right to live free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. Concerns were shared promptly and appropriately by the provider.

Robust systems were established to maintain safety. Staff received regular safeguarding training and had access to comprehensive information on how to report concerns. They demonstrated familiarity with reporting procedures and a strong understanding of safeguarding principles.

Incidents and accidents were regularly reviewed, with thorough investigations conducted to identify causes. Appropriate actions were taken to minimise risks and prevent recurrence, supporting continuous improvements in safety.

People and their relatives reported individuals were safe within the service. Safeguarding concerns had been appropriately reported to the local authority and the Care Quality Commission (CQC) when required. Management worked collaboratively with the local authority to resolve safeguarding cases in a timely and effective manner.

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. Risk assessments included clear plans outlining how identified risks should be mitigated. Wherever possible, people were involved in developing their own risk management plans, and family members also contributed to the planning process.

Although some individuals were not always able to verbalise their wishes, staff were familiar with their methods of communication and supported them to engage in activities while effectively managing associated risks.

At times, people expressed anxiety through physical behaviours. Staff followed established support plans to de-escalate situations and assist individuals in expressing their emotions appropriately. Both relatives and staff confirmed these approaches were effective and contributed to keeping people safe.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The environment was regularly checked by staff and external maintenance workers to make sure it was safe. Staff completed regular health and safety checks such as fire systems checks. Any faults were reported to external maintenance workers and we found these had been addressed promptly.

Facilities and equipment had regular service checks carried out which made sure equipment was safe for people to use. We saw staff using equipment safely during our site visits.

Staff at Ashdale were comprehensively trained to deliver high-quality, person-centred care tailored to the complex needs of the individuals. Training programmes ensured staff were equipped with the necessary skills and knowledge in areas such as safeguarding, medication administration, communication, and health and safety.

Staff deployment was carefully planned to ensure sufficient numbers of skilled personnel were available on each shift to meet the diverse and evolving needs of people. This effective staffing arrangement supported the delivery of safe, consistent, and responsive care throughout the day and night. Staffing levels were maintained at an appropriate and consistent level, ensuring that people received timely assistance and meaningful engagement. This contributed to a stable care environment where people’s safety, wellbeing, and individual preferences were prioritised.

The registered manager played an active role in supporting the staff team, providing clear leadership, supervision, and opportunities for ongoing professional development. Regular team meetings and one-to-one support helped maintain staff morale, encourage reflective practice, and address any challenges promptly. The provider had effective recruitment policies and procedures in place.

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.

All staff completed regular training in infection prevention and control, which covered key areas such as hand hygiene, the correct use of personal protective equipment (PPE), and cleaning protocols.

There was a readily available and sufficient supply of PPE throughout the service, including gloves, masks, aprons, and hand sanitiser. Staff demonstrated appropriate use of PPE during the inspection and understood when and how to use it to minimise the risk of cross-contamination.

The environment was visibly clean, hygienic, and well maintained. Communal areas, bedrooms, bathrooms, and kitchen facilities were subject to regular cleaning schedules. High-touch surfaces were cleaned frequently to reduce infection risks.

The provider carried out routine audits of infection prevention and control practices, which included cleanliness checks, observations of staff practice, and reviews of cleaning records.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Accurate and up-to-date medication administration records (MARs) were maintained for each individual, documenting the medicines administered, dosage, and times. These records ensured clear audit trail and facilitated the monitoring of adherence to prescribed treatment.

Where ‘as required’ (PRN) medicines were prescribed, detailed protocols were in place to guide staff on the indications, dosage, and administration of these medications. These protocols supported consistent and safe decision-making to meet individuals’ needs.

Staff responsible for administering medicines underwent regular competency assessments to confirm their knowledge and skills in safe medication management. These assessments included practical observation and theoretical evaluation to ensure adherence to best practice standards. Only staff who had demonstrated competency were authorised to administer medication.

The provider maintained a robust incident reporting system for any medication errors or near misses. When medication-related issues occurred, they were promptly investigated, and appropriate corrective actions were implemented to prevent recurrence. This included reviewing and strengthening systems, providing additional staff training, and updating protocols where necessary to safeguard people’s health and wellbeing.

Regular medicines audits were conducted to verify all medicines, including controlled drugs, were accurately accounted for and recorded. These audits reviewed storage conditions, record keeping, and compliance with prescribing instructions, thereby ensuring ongoing safety and regulatory compliance. Any medicine errors were appropriately investigated and lessons were learnt.