Ash Cottage

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 inadequate. This meant people were not safe and were at risk of avoidable harm.

This service was in breach of legal regulation in relation to safe care and treatment, safe staffing levels and the governance at this service.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice. Accidents and incidents were analysed. However, trends and themes were not always identified and there were a high number of unexplained injuries occurring. Lessons learnt processes were not being shared with staff until a professional visited the service prior to our assessment and raised this. Therefore, we could not be assured lessons learnt processes were fully embedded which would help prevent future risks occurring.

Relatives raised some concerns in relation to people’s safety, and one relative felt the high amount of over chair tables could pose as a hazard to people who were at risk of falls. A professional spoke of the difficulties in staff reporting concerns to them, they did however say this had improved recently.

Staff knew the process should someone fall. They said, “We don’t have a lot of falls and how we manage this depends on severity.” The registered manager told us there was a clear system for reporting and reviewing accidents, incidents and complaints. They said, “We always focus on what we can do better, not who is to blame.”

The service worked with people and healthcare partners to establish and maintain safe systems of care, to ensure there was continuity of care, including when people moved between different services. People were transferred to hospital safely. Essential information was sent with the person to inform hospital staff on how to safely care for people. Hospital staff could access a person’s care records by being supplied a temporary log in of the service’s electronic care records. Initial assessments were carried out for new people coming into the service which were then used to develop care plans.

Staff told us about the process for new admissions to the service. They said, “Initial assessments are completed and this information is handed over to staff. I have a printed list, so staff know what to do when a new person comes into the home (service).” The registered manager told us how people were moved between services safely. They said, “When people move between services, we send a full up to date summary including risks, medication, communication needs and behavioural support plans.”

The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. Staff told us they had received training in safeguarding and were aware of how to report concerns. However, staff lacked understanding of the meaning of DoLS (Deprivation of Liberty Safeguards) and were not always able to tell us what this meant or who had this authorisation in place, despite several people living at this service under a DoLS authorisation. Therefore, we could not be assured people were being deprived of their liberty safely and lawfully. A safeguarding policy was in place which detailed the signs to look for regarding different types of abuse. However, the safeguarding policy did not hold the name and contact details of the registered manager or safeguarding lead to guide staff should they have any concerns.

People and their relatives raised no concerns in relation to people’s safety. One relative said, “It’s the first time I’ve had any dealings with a care home for any member of the family and it’s brilliant. I can’t find anything wrong.” Outcomes were available for recent and past safeguarding concerns; however, it was not clear any discussions had been had about reducing future risks.

The service did not work well with people to understand and manage risks. They did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. People’s specialised diets were not always recorded accurately, and we observed one person being given the incorrect diet. Staff, including the chef, were not aware of people’s specific dietary needs which placed people at risk of choking. Person-centred plans were in place for people who were diabetic, however, the food on offer was not always tailored to meet the needs of people who should follow a diabetic diet. Not all pressure relieving equipment was used appropriately and this placed people at risk of skin breakdown.

Staff told us how distressed behaviours were managed. They said, “Some people have challenging behaviours. We fill in behaviour charts and monitor behaviours.” We did see evidence of behaviour charts being completed; however, they lacked detail and did not record whether staff intervention had helped the person. This meant there was no evidence trail recorded of what helped a person in times of distress to reduce future risks.

The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care. We identified numerous concerns relating to the environment of this service. The kitchen door had no lock on day 1 of our visit. This was rectified immediately, however, when we returned on day 2, the door was not locked which meant people could walk into the kitchen and be placed at risk. The kitchen storeroom was also unlocked, and the kitchen extractor fan had been broken for some time. The garden was overgrown and contained clutter and one mattress was overhanging the bed which despite being mentioned on day 1, this was still the case on day 2 of our site visit.

Fire safety concerns were noted including one bedroom door which had not closed for some time and no action had been taken, the PEEPS (Personal Emergency Evacuation Plans) file contained information about people who no longer lived at this service. Staff were not sure what to do should a fire occur and we received conflicting accounts. One staff member said, “(If there was a fire) we do not evacuate people or take them outside as they might get hypothermia.” This goes against the service’s own fire safety policy. We were not assured people would be evacuated safely should a fire occur. We did see evidence of regular servicing of equipment such as slings and hoists.

People and relatives raised no concerns in relation to the environment, however staff raised concerns in this area. They said, “I have concerns over maintenance issues. Things just aren’t getting done, you report them but there is no action.” We saw evidence that the registered manager had been reporting the same maintenance issues repeatedly and no action had been taken to address the concerns raised. However, we observed maintenance staff in the service on day 2 of our assessment undertaking some tasks.

The service did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs. Some people and relatives raised concerns in relation to staffing levels. One person said, “They (staff) do get rushed at times, but they get things done but could probably do with more staff at busy times.” Staff also felt more staff were needed. Staff comments included, “We need more staff, 2 people is not enough. It can be rushed especially in the mornings” and, “There isn’t enough staff, we need 1 extra carer (staff) when [people] become distressed, they (people) need 1-1 care when distressed.” A dependency tool had been implemented during the assessment process. When we asked the leaders of this service during their feedback call what action would be taken to address staffing levels and ensure people were safe when they became distressed, we did not receive a clear plan of action. Therefore, we could not be assured people were being kept safe.

Staff told us they had completed training including face to face courses. However, when we reviewed the training matrix, we found some gaps in staff knowledge including the management of distressed behaviours and continence care. A few gaps were noted in staff recruitment, however, overall staff recruitment processes were strong and could perhaps be made more robust through auditing processes.

The service did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly. Although we found the environment to be generally clean, we identified several issues including scuffed walls, staining to the ceiling in communal areas, radiator covers dirty and rusty, dirty light pull strings, damaged walls and skirting boards and excess toilet roll stored on the back of some of the toilets as no toilet roll holders were present. These concerns had been identified through a professional audit in October 2025 and had not been addressed.

The kitchen contained out of date food items and personal items were being stored amongst kitchen utensils and on shelves which could lead to cross contamination. Staff were found to not always be wearing PPE (Personal Protective Equipment) appropriately and we observed a workman enter the kitchen with no PPE on at all. Bedding was thin and of poor quality.

People and relatives told us the service was clean and tidy. One relative said, “The place (service) is clean, and the cleaners (domestic staff) are always doing (working).” Spot checks were in place alongside observed practices to ensure staff were following good Infection Prevention and Control (IPC) procedures. Hand hygiene posters were displayed around the service as well as PPE stations for staff to access PPE equipment.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We found discrepancies in one person’s medication records for several of their medicines. This meant the person either had too many doses or missed doses of their prescribed medication. This was despite staff signing the stock count each day. Some creams and liquids were open but not dated. This meant we could not be assured they were safe to use or if the medicine would still be effective.

People and their relatives raised no concerns in relation to medicines. One person said, “They (staff) are very stringent about medication which is a good thing.” Staff told us about the process for ordering, administering and returning medicines and supporting policies were in place for this. Medicine records including guidance on high-risk medicines and when required medicines guide staff on when these medicines needed to be administered. Topical creams were administered and signed for by care staff and included a body map to guide staff on where to apply them.