Ash Tree

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 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 62 (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. Relatives told us they were informed and involved if there were any concerns about their family member’s safety. They told us, “I see staff every week and they keep me informed about what [Name] has been doing, and if any issues have occurred.” Staff were knowledgeable about any actions taken and changes made to people’s care in response to safety incidents or concerns. For example, they followed directions around supporting and supervising people to reduce the risk of falls or them becoming distressed.

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. Staff worked closely with health and social care partner agencies to ensure effective communication and that people received the care and treatment they needed. Staff provided advocacy for people to ensure their views and wishes were heard and respected during assessments and reviews, including potential transitions to new placements.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.  People looked comfortable and relaxed with the staff who supported them and with each other. A person told us they felt safe and ‘really liked all the staff.’ Staff understood their roles and responsibilities in keeping people safe, felt confident to raise concerns and were confident these would be acted on. Staff followed best practice and supported people in the least restrictive way possible to safeguard their liberty and freedom.

The provider worked with people to understand and manage risks by thinking holistically. However, potential environmental risks had not always been acted on in a timely way. For example, we found flooring with duct tape to alert people to a slight step or incline, a toilet that was too close to a radiator presenting a risk of contact and some furniture was worn with broken parts. Despite this, staff strived to provide care to meet people’s needs that was supportive and enabled people to do the things that mattered to them. The registered manager promoted a culture of positive risk taking and enablement rather than simply providing care. Risks were assessed and managed; people and their relatives were involved in this process. For example, a person was enabled to make their own hot drinks and drinks for others when they wished. A second person was assigned a constant staff member so they could get up and walk around when they wished, which mitigated the risk of falling without unnecessarily restricting them.

The provider did not always detect and control potential risks in the care environment. The provider had made some improvements to the environment, including a new kitchen and dedicated laundry room and office. However, they did not always make sure timely adaptations, and make reasonable adjustments to meet people’s individual needs. For example, a person had moved to a ground floor room to aid potential mobility issues. However, the room had no shower/bath/toilet facilities, and none were available on the ground floor so they still need to use stairs to access these. Areas of the premises were in need to redecoration and refurbishment. These included substantial cracks in brick work, taped carpet areas, a poorly decorated bathroom with bare exposed wood and stained grouting, and generally poor maintenance. Additionally, we found some recommendations from the fire risk assessment had not been acted on or reviewed. Following our inspection, the registered manager submitted evidence of approved plans to provide bathing facilities on the ground floor, acted on fire risk assessment recommendations and identified plans for redecoration and refurbishment. People were proud to show us their rooms and these had been personalised and decorated in line with their preferences and wishes.

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. A relative told us, “The staff are great and really seem to understand [Names’] needs and requirements. Staff completed training in areas identified as necessary for the service, including training on how to support people with a learning disability or autistic people. A staff member told us, “Training and induction is good. I had books to read and work through, shadow shifts, and got to know about people through working with staff who knew them and from care plans. This provided all the information I needed to understand how to support people.”

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. Staff followed infection control guidelines and we found the environment was clean, although some areas were cluttered.

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. Systems and processes to safely administer, record and store people’s medicines were in place. However, we found a cabinet containing stock medicines for everyone in a person’s room. We asked the registered manager to relocate this to a more appropriate area. Medicines were administered as prescribed. Staff administering medicines had appropriate training and the management team maintained good oversight through regular audits and checks. Staff ensured medicines were reviewed if people’s needs changed, and in line with ‘Stopping over medication of people with a learning disability and autistic people (STOMP)’