Ash View

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 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 have a proactive and positive culture of safety based on openness and honesty. Records showed lessons learned were discussed and shared through team meetings and operational forums, with management identifying actions following incidents and concerns. However, despite evidence of learning being recorded, improvements were not always embedded or sustained in practice. For example, recurring medicines errors, documentation issues and governance concerns continued to be identified, indicating that learning was not consistently translated into effective action or service-wide improvement. This reduced assurance that systems for learning, reflection and continuous improvement were operating effectively.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff worked in partnership with the local authority to support safe admissions and transitions into the service. People were given opportunities to visit the service and meet staff before moving in. However, managers told us information received at the point of admission was not always up to date or accurate. For example, referral information sometimes included medicines that people were no longer prescribed or taking, which meant additional checks were required to ensure care plans and support arrangements accurately reflected people’s current needs.

Records showed the service had identified individuals experiencing repeated falls and had made referrals to specialist falls teams, implemented falls sensors and sought reviews of support arrangements where appropriate.

Safeguarding systems and oversight were not consistently effective. Staff understood their responsibility to raise safeguarding concerns and told us they would report issues to managers. Safeguarding records were not consistently completed, with gaps in key information including event dates, safeguarding reference numbers and closure dates. It was not always clear whether concerns had been referred to the relevant local authority or whether management reviews and lessons learned had been completed. These recording inconsistencies reduced the provider’s ability to demonstrate effective oversight and assurance that safeguarding concerns had been appropriately managed, investigated and closed in line with local safeguarding procedures.

Although safeguarding governance required improvement, staff were able to describe different types of abuse and were clear about their responsibility to recognise and report safeguarding concerns to protect people from harm.

The provider worked with people to understand and manage risks by thinking holistically. People were actively involved in identifying and managing risks associated with their care. Staff reviewed care plans and risk assessments with people and completed regular reviews, ensuring individuals had opportunities to discuss and influence how risks were managed. Where appropriate, staff supported positive risk-taking to promote independence. For example, one person assessed as being at high risk of overdose was supported to self-administer their medicines under staff supervision, balancing safety with the person's right to maintain choice and control.

The provider generally maintained environmental risk assessments which identified potential hazards and the control measures in place to reduce associated risks. These included assessments relating to the premises and equipment, such as bed rails, to help ensure people's safety. However, we found infection prevention and control measures were not always consistently maintained. For example, soap was not available in communal handwashing areas, which meant people, staff and visitors did not always have access to appropriate hand hygiene facilities and increased the risk of the spread of infection.

Systems to ensure safe and effective staffing were not always effective. The provider relied heavily on agency staff; however, governance arrangements did not provide assurance that all staff deployed within the service had the necessary skills, knowledge and competencies to meet people’s needs safely. Feedback from people, relatives and staff identified concerns regarding agency staff communication, professionalism and consistency of care. Some people told us agency staff did not always introduce themselves, wear name badges or communicate effectively, which negatively impacted their experience of care.

A review of the provider’s training records showed training compliance was not consistently maintained across the workforce. We identified gaps in several mandatory training areas, including moving and positioning, aspiration, choking and dysphagia, emergency first aid and medicines management. Whilst systems were in place to monitor training, these had not always been effective in ensuring staff completed required training within expected timescales.

However, staff had access to regular team meetings and supervision, providing opportunities to discuss practice, performance and development needs. Overall, improvements were required to ensure staffing arrangements, competency monitoring and workforce oversight were consistently effective in supporting safe care. At the time of the inspection, the provider had recently recruited a number of new staff who were undertaking their induction and mandatory training.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The provider did not consistently maintain appropriate standards of cleanliness and hygiene within the service. During both inspection visits, communal and staff toilets were found to be without soap, despite this having been raised with management during the first inspection day. Some toilet facilities also had limited or no toilet paper available.

Whilst managers advised responsibility for replenishing these items rested with the local authority, effective oversight arrangements were not in place to ensure basic hand hygiene facilities remained available to people and staff. This meant the provider had not taken all reasonable steps to promote good hygiene practices.

During the inspection, we observed staff and people using the service preparing food in communal kitchen areas where soap was not available for handwashing. This meant appropriate hand hygiene could not be maintained, increasing the risk of cross-contamination and the spread of infection.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. A review of incident records between 7 September 2025 and 8 September 2026 identified over 90 medication-related incidents, including administration errors, dispensing errors, near misses, stock supply issues and medicines documentation errors. We found poor medicines-recording practices were recurring across the service rather than being isolated incidents, including incomplete MAR records and recording discrepancies.

Medicines audits were completed and identified areas of concern; however, it was not always clear what actions had been taken in response. This was evidenced by recurring medicines errors and recording issues, indicating that audit findings were not consistently used to drive and monitor improvements in practice.

Oversight of staff training and competency was also not consistently effective. Training records showed that eight staff members had either not completed, or were overdue, training in the Safe Management of Medicines for Social Care Staff. This was particularly concerning given the medicines management issues identified during the inspection. The service manager's medicines training was also out of date. These findings meant the provider could not demonstrate that all staff responsible for administering medicines had the appropriate knowledge and skills to do so safely.

However, the registered manager told us the provider was in the process of changing the pharmacy provider to help address some of the medicines management issues and improve the accuracy and reliability of medicines systems.