Ashley Drive

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 inspection we rated this key question good. At this inspection the rating has remained Good. This meant people were safe and protected from avoidable harm.

This service scored 72 (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.

The provider had up-to-date policies in place to support staff to report accidents and incidents. The provider focussed on investigating events and identifying lessons learnt and actions to be taken where things had gone wrong and ensured these were communicated to staff in their team meetings, supervisions, and handovers. A professional told us, “Ashley Drive are exceeding at working with a multi-disciplinary team investigating safety events and take appropriate actions. They take on constructive feedback, learn lessons… and take actions when changes are required.”

People’s relatives had been kept up to date during investigations where their loved one had been identified as being at the increased risk of harm due to safety concerns which had taken place in the service. They confirmed they felt assured the provider was working hard to assure people were safe. A person’s relative told us, “[The service] have been very transparent. We had a families meeting after [safety event] had occurred, and [the provider] apologised. They have kept us in the loop with all the changes since.”

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.

The provider had processes in place to help ensure people were safe when receiving delegated healthcare tasks, including Percutaneous Endoscopic Gastrostomy (PEG) care. Staff received appropriate training, and registered managers were trained to assess and confirm staff competency. The provider worked proactively with external professionals to address barriers and advocate for people’s needs, while ensuring alternative clinical support was available to maintain continuity of care and minimise disruption.

The provider advocated on people’s behalf to ensure safe, continued, care when accessing different services, for example, a person was supported to secure funding to assure their safety using transport, so they could access their education. The provider supported the person with securing their own private vehicle to improve their future access to further services.

The provider helped to ensure transition into the service was smooth. A person’s relative told us, “It was seamless and really helped ease [relative’s] feelings about [person] moving.” A professional told us, “Ashley Drive have been central in contacting the hospital and requesting discharge planning meetings for a [person] in hospital awaiting discharge home…which evidence they are proactively considering how they can keep the service user safe on their transition from hospital to home.” This meant people experienced continuous, safe care when moving between services.

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 were supported by staff who understood their safeguarding responsibilities and knew how to recognise and report concerns. The provider took appropriate action when concerns about staff practice were identified, to help reduce risks and protect people from the increased risk of avoidable harm. A professional told us, “Ashley Drive are always very timely in alerting [professional] of any incidents.”

The provider had an up-to-date safeguarding policy, and safeguarding was regularly discussed in team meetings to promote learning and awareness. People and their relatives agreed they felt safe using the service. A person told us, “I would speak to staff [if I didn’t feel safe].”

Where required, the service applied the principles of the Mental Capacity Act 2005 and supported people subject to Deprivation of Liberty Safeguards (DoLS). This meant people were supported in an environment where safeguarding processes were understood and acted upon, helping to keep them safe from abuse and avoidable harm.

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

People were supported by staff and managers to identify, manage and reduce risks to their health, safety and wellbeing. Risk assessments included people and their relative’s input, were detailed and provided clear guidance for staff to care for people safely. Staff supported people to take part in activities they enjoyed and make choices about their lives, while managing risks in a positive and proportionate way. Where people’s needs required constant monitoring, staff monitored their wellbeing in a discreet and least restrictive manner to help keep them safe. This meant people were supported to live as independently as possible while receiving safe care and support which balanced choice, control and safety.

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.

People did not have risk assessments in place for the use of paraffin-based creams. We gave feedback to the provider, and this was put in place without delay. We identified some inconsistencies in staff recording of water temperature checks and visual checks of equipment. We found staff had recorded fridge temperatures outside the recommended range and had not escalated this, however, on feedback, management identified this was down to a faulty thermometer. This meant there were missed opportunities to strengthen recording and escalation processes.

The service environment was clean, well-maintained and met people's needs. The provider carried out regular checks and took action to address maintenance issues promptly. Required safety assessments, including fire and legionella risk assessments, were up to date, and equipment such as hoists and wheelchairs were serviced and maintained appropriately. The provider had plans in place to re-decorate the service. Sensory spaces were available, and the service worked with healthcare professionals to ensure people had access to equipment which met their individual needs.

Staff had received fire safety training and participated in regular fire drills. People had personalised Personal Emergency Evacuation Plans (PEEPs) which provided staff with clear guidance on how to support them safely in an emergency. Appropriate signage was used throughout the service to promote safety and awareness of risks. This meant people were supported to understand their environment.

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.

The provider ensured staff completed required training and competency assessments to support them in carrying out their roles safely. Recruitment processes were followed to help ensure staff were suitable to work with vulnerable people, including completion of Disclosure and Barring Service (DBS) checks.

At the time of the inspection, the provider stated they were using bank and regular agency staff to cover staffing shortfalls arising from vacancies and other workforce pressures.

A person’s relative told us, “There is always someone available to talk to. There is always someone with [people] in the lounge.” This meant people were supported by a consistent staffing team, who knew how to safely care people’s needs.

Staff received supervision, training and development opportunities. Where supervision had not always been completed in line with the provider's arrangements, action had been taken to improve oversight and support consistent delivery.

Team meetings were held to share information and support communication; however, records did not always evidence staff engagement or contributions to discussions.

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 prevention and control (IPC) procedures, including the appropriate use of Personal Protective Equipment (PPE) when providing care and support. The service environment was clean, tidy and well maintained, and had recently undergone a deep clean. People's bedrooms were clean and free from malodours. Cleaning schedules and checks were completed and monitored, and staff had received training in food hygiene.

People’s relatives told us, “We saw the deep cleaners in when we went to visit [person]. [The manager] was really good and made sure they didn’t miss anything.” This meant people were protected from the increased risk of harm caused by the spread of infection.

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.

We observed people receiving their medicines from trained staff who supported them safely and in line with their assessed needs, for example, with soft food to aid swallowing.

Staff recorded this on Medicines Administration Records (MARs), which included clear protocols for medicines prescribed on an 'as required' (PRN) basis. During the inspection, we observed staff responding promptly when a person requested pain relief and support them to take their medicine without delay.

Staff recorded the reasons for administering PRN medicines and had recently ensured staff recorded whether the desired effect had been achieved. We gave feedback to the provider about this. The provider worked with healthcare professionals and pharmacies to help ensure medicines were ordered, stored and monitored safely, including through regular stock checks. People were supported in line with STOMP (Stopping Over Medication of People with a Learning Disability, Autism or Both) principles.

Staff recognised and reported medicines errors appropriately and sought professional advice when required. Records showed staff documented when and where topical medicines, such as creams, had been applied.

This meant people were supported to receive their medicines safely by staff who followed established processes and sought professional input when needed.