Ashley Court

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 service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People and their relatives told us they knew how to raise concerns and were confident they would be listened to. A relative said, “I would go to [name], nurse in charge. I feel I could go to any of them. Anything that needed resolving was sorted.”

The service had an effective system in place for reporting and reviewing incidents and accidents. The registered manager reviewed incident reports from across the service regularly, to identify trends and themes. People’s care plans and risk assessments were updated regularly.

Lessons learnt and reflective practice were discussed during monthly meetings. These included the principles of Mental Capacity Act (MCA), communicating with people living with dementia and improvements to people’s care.

Staff confirmed they felt they could discuss any concerns or issues with the registered manager. and felt comfortable to do so.

The service 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.

Health and social care professionals were complimentary about working with the service.

Relatives told us people had access to healthcare professionals, and they were informed of any changes to people’s care. The service used an electronic care planning system and recorded information relating to health appointments on the system. This ensured all staff had an easy access to information which was kept up to date.

The provider had an established process in place to ensure person’s documentation is up to date and printed in case of emergency hospital admission. The provider also had a paper-based form that could be completed and used instead, if for example the internet was down and staff could not print person’s documentation.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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 service shared concerns quickly and appropriately.

Staff told us they knew how to raise concerns with the registered manager and felt people were safe living at the service. Staff told us they could report any concerns they had externally to the local authority or CQC. Comments included, “I always ensure clients safety with proper care. We follow care plans, risk assessment and safeguarding procedures”, “I feel comfortable speaking up at work and I believe my voice will be heard. If I have any concerns about a resident’s safety, care, or the environment, I report it to the nurse in charge or the senior staff. They listen and take action when needed”, and “I believe our clients are safe because we follow safety policies, monitor patients regularly, and report any concerns immediately. We always prioritise people safety and wellbeing.”

The service had a process to ensure people were protected and concerns were reported to the local authority without delay. The registered manager had an effective oversight of this system.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care services, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. All legal applications had been made in accordance with DoLS. This meant people’s rights were fully respected. The registered manager had oversight of DoLS applications.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People had risk assessments in place which were completed by the clinical staff and reviewed regularly. They determined the risk level and what risk mitigation was required. Key risks to people were clearly documented in the relevant support plans and ‘critical instructions’ of the electronic care planning system as well as handover documents.

Some risk assessments were not visible to staff who used handheld devices to access the electronic care planning system used by the service. The provider responded to our feedback by reaching out to the electronic care records provider to ensure this would be rectified. Whilst this was completed, the service ensured all relevant information was transferred onto the part of the system visible to all staff.

Relativestold us they felt people were safe. One relative said, “[Person] is very safe. The service is fantastic.” Another person told us, “[Person] is safe and well looked after. If there is anything [I need to know about], they are on the phone to me.”

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

People had Personal Emergency Evacuation Plans (PEEPs) in place. PEEPs provide staff and emergency service personnel with information on how people would need to be supported to safely evacuate in the event of an emergency.

The provider used external contractors to undertake some checks, including in relation to legionella, gas and electrical safety. Equipment seen during the inspection was checked by qualified professionals and well maintained. This included hoists and mobility bathtubs.

The service had a plan of action for any maintenance related works. This was a live document which was regularly updated and reviewed. Staff told us they knew how to report maintenance concerns when necessary. A staff member said, “Maintenance issues or concerns are reported to the manager of the care home and yes, they are well addressed. Managers do their best to resolve the issues as soon as they can, to keep true premises safe for the staffs and residents.”

A relative said the service looked “homely.”

When appropriate people had personal display cabinets for the safe keeping of recognisable, personal memorabilia outside of their bedrooms.However, these were not always completed. Some areas of the service required updating and introducing more dementia friendly decorations and signage. The provider responded to our feedback and planned to review areas of the service to ensure they are dementia friendly and meet people’s needs effectively.

The service 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.

Recruitment procedures were in place to ensure checks were carried out on staff before they commenced their employment. This included enhanced Disclosure and Barring Service (DBS) checks for adults. DBS checks provide information including details about convictions and cautions held on the police national computer. The information helps employers make safer recruitment decisions.

Staff had regular supervisions and attended team meetings.These were planned in advanced and the registered manager had a detailed overview of all planned meetings. Training records showed staff had the necessary training, skills and knowledge to carry out their roles.

The service had a system in place to determine the number of staff required in relation to people’s needs.According to the system in place, there were enough staff to meet people’s needs safely. Staff’s rotas were planned in advance to ensure the service had sufficient numbers of suitably qualified and competent staff on each shift.

We used the Short Observational Framework for Inspection (SOFI). SOFI is used to capture the experiences of people who are unable to communicate their experiences with us. We found not all staff communicated with people when supporting them to eat. We also found some people were not always engaged in activities available to them. Some people said they were “bored” and 1 person said it was “boring and dull”.

Following our feedback, the registered manager confirmed that they will review individuals’ engagement to determine whether it can be further enhanced.

The registered manager regularly spot-checked staff working across all 3 floors of the service. Records showed staff performance was routinely monitored outside standard working hours. This supported the management to have an oversight of care delivery across a 24-hour period.

People and relatives were complimentary about staff. Comments included, “They are lovely and friendly”, “They're polite, caring, they're all approachable”, “Really professional”, and “Lovely bunch of people, they try to make you feel at home.”

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

We observed the premises to be clean. A relative told us, “[The service] always smells lovely and clean.” A person said, “The cleaner is very good, we are impressed with them.”

The service had achieved a 5 rating in relation to food hygiene. This meant food safety was assessed as being ‘very good’. We observed the kitchen to be clean.

Personal Protective Equipment (PPE) was available to staff. A staff member told us, “We have PPE such as gloves, aprons, masks, and hand sanitiser. When supplies are running low, we inform the senior staff or check the storage area and restock from there.”

Staff had completed infection prevention training, and the provider had an up-to-date policy in place.

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

Staff confirmed they knew what to do in case of an error occurring and they were spot checked by leaders and had the necessary training in place. A staff member said, “I support people with medication administration. If I discovered a medication error, I would first ensure the person’s safety and wellbeing. I would then inform the senior member of staff or manager immediately, follow the service’s medication error procedure, document the incident clearly, and complete the necessary reports. If required, medical advice would be sought to ensure the person remains safe.”

We observed safe medicine administration and staff asking for consent before administering medicines to people. We observed the medicine room to be clean and well organised.

The service worked closely with healthcare professionals regarding medicines management. Protocols were in place for people who were prescribed additional medicines. These were person centred and well written.