Ash 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 newly registered service. This key question has been rated 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.

The service was in breach of the legal regulation in relation to safe care and treatment.

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 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 time of inspection, learning from safety incidents and risks was not consistently effective, which limited assurance that the service was learning from events to prevent harm and improve safety. While incidents were recorded, there was limited evidence to demonstrate what learning had been identified or how this had informed changes to practice.

Records showed that incidents were not always escalated promptly and documentation was not always completed accurately or in a timely way. For example, records showed that following an incident where a person sustained an injury, the incident was not immediately escalated by the staff member on duty and was later identified and reported by staff on the following shift. We found limited evidence to demonstrate how learning from this incident had been shared with staff or used to reduce the risk of similar incidents occurring again.

Staff we spoke with described an understanding of how incidents should be reported and escalated. However, this was not consistently reflected in practice, and learning from incidents was not clearly embedded in people’s care. This meant we could not be assured that incidents were being used to improve safety.

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.

There were systems in place to ensure people’s needs were appropriately assessed before they started using the service. These included a combination of face‑to‑face assessments and reviews of relevant records to inform safe admissions.

Relatives told us they felt involved in the assessment and transition process and their loved ones were supported during times of transition. One relative told us staff worked closely with them and other professionals when needed. Another, relative said, “They really looked after her whilst she was in hospital; they were always there.”

Staff explained they received relevant information about people prior to admission, which helped them understand individuals’ needs and preferences and supported continuity of care when people transitioned into the service.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always 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 always share concerns quickly and appropriately.

People’s experiences were mixed. Relatives told us they were kept informed following incidents. For example, 1 relative said, “They always keep me informed when an incident occurs.” However, another relative told us that following an incident they had lost confidence and were not reassured that staff were able to keep their family member safe.

Safeguarding incidents were not always escalated or investigated in a timely way. Records showed delays in reporting and gaps in documentation following incidents that placed people at risk of harm. Where safeguarding concerns had occurred, information was not always recorded, and there was insufficient evidence to demonstrate that immediate risks were fully considered and addressed. This meant people may not have been adequately protected following incidents, and the risk of further harm was not always reduced promptly. Staff told us they understood how to recognise and report safeguarding concerns and were able to describe the process for escalating issues to managers and external agencies when required. However, this understanding was not consistently reflected in practice, as safeguarding concerns were not always managed promptly or evidenced clearly within records.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found no concerns and Deprivation of Liberty Safeguards (DoLS) were in place for people when needed.

Following inspection feedback, the provider shared actions to strengthen safeguarding processes, including increased oversight, improved monitoring, and learning shared with staff. We will check this action has been effective at our next inspection.

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

While systems were in place to assess and record risks, these were not consistently used to support people with a learning disability and/or autism to take positive, managed risks. Therefore, we could not be assured that care was delivered in line with the principles of Right Support, Right Care, Right Culture.

Risks to people were not always effectively managed. For example, where a person had been assessed by Speech and Language Therapy (SALT) as requiring a modified diet to reduce the risk of choking, care plans did not consistently provide clear guidance for staff to follow. Records showed foods provided did not always align with professional guidance, and there was limited evidence to demonstrate how this risk was being managed in practice. As a result, we could not be assured that professional guidance was consistently followed, and this placed the person at risk of unsafe care.

Environmental risks were also not always identified or addressed. During the inspection we observed communal areas used by people to access the garden were cluttered, with equipment and items not in use. This included stored boxes and mobility equipment, which increased the risk of trips, falls or injury. This indicated that risks within the environment were not always managed promptly to keep people safe.

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.

We observed several items being stored in a communal lounge, including a microwave, pushchair, scooter, wheelchair and PPE on the floor, and another microwave, an air fryer and a toaster on a windowsill. We also saw cleaning equipment, including buckets and mops, stored at the end of a shared hallway. While these were positioned to 1 end of the corridor, storing multiple items in a communal area increased the potential for clutter in a space used by people moving around the service. This showed that environmental risks were not always identified or addressed in a timely way prior to the inspection.
 

However, people’s own bedrooms were observed to be clean, tidy, and well managed. These areas were personalised and maintained in a way that supported people’s comfort, dignity, and safety.
 

During the inspection, the provider took immediate action to remove items from the communal lounge which reduced the risk to people. We will check this action has been maintained at our next inspection.

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.

Relatives told us they were satisfied with staffing arrangements. One family member told us they were happy with the care provided and felt staff were suitably trained to support their relative safely.

Staff we spoke with confirmed they had completed all required training relevant to their roles. One staff member told us, ‘We receive regular and ongoing training’, including refresher training, they felt this equipped them with the knowledge and skills needed to support people safely. One staff member told us they received ‘lots of training,’ which helped them understand people’s needs and how to manage risks appropriately. The registered manager told us they had checks in place to confirm staff were suitable to work with people as part of their recruitment process. Records we saw confirmed what we were told.

Staffing levels at the service were sufficient to meet people’s needs safely. People were supported by staff who knew them well, and there was a level of consistency in staffing which helped staff to understand people’s preferences and routines.

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.

Infection prevention and control procedures were in place and were implemented. During the inspection, we observed staff using appropriate personal protective equipment (PPE), including gloves and aprons when providing care and carrying out tasks where this was required.

The service had sufficient supplies of PPE available, and staff knew where to access this. One staff said, “We have enough gloves, aprons, and enough cleaning materials.”

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

We saw Medication Administration Records (MAR) were handwritten, and there was no evidence to confirm that medicines information had been accurately transcribed from prescriber’s instructions. For example, there was no second signature to confirm the transcription had been checked by another member of staff. Although monthly medicines audits were in place, the most recent audit had not yet been completed at the time of inspection. As a result, there was no evidence that the handwritten MAR charts had been reviewed for accuracy.

This increased the risk of medicines not being administered in line with how they were prescribed, which could place people at risk of harm.

Where people were prescribed medicines that required refrigeration, we found that fridge temperatures were repeatedly recorded outside the required range. For example, during February, the majority of recorded temperatures were out of range, with no clear documentation to show these deviations were acted upon or escalated, despite temperatures continuing to fall outside acceptable parameters. This meant the effectiveness of the medication could not be assured, increasing the risk that people may not receive the intended benefit from their medicines.

However, relatives we spoke with raised no concerns about how medicines were administered to their family members. Staff told us they had received medicines administration training and confirmed this helped them understand medicines administration practices.