Ashcroft Care Home

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 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.

The service was in breach of legal regulation in relation to people’s safe care and treatment.

This service scored 44 (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 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.

Records we viewed did not consistently show there was a proactive learning culture regarding health and safety incidents or concerns, and that these had not been effectively reflected upon and used to drive improvement.

Incidents were recorded and an analysis created,however they did not clearly detail what action had been takenin order to monitor the effectiveness of changes.

The provider had not learned lessons from previous incidents or taken sufficient steps to prevent recurrence. As a result, the same shortfalls persisted and continued to impact people’s experience of care. This meant people were at continued risk of harm. We asked the provider to take action on the shortfalls found, which they started to take action immediately.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

A relative told us, “Ashcroft was the only provider to take the time to visit my Mum in hospital, to meet her and talk to the nursing team, so they were confident when they offered a place that they could take care of her and meet her needs.”

Staff said, “If an individual needs to go to the hospital in an emergency a staff member will attend with them in the ambulance taking along all relevant paperwork such as, respect form, next of kin details, list of medication, any allergies, any other important information.”

However, we found inconsistencies in peoples records regarding the care and support they required. This placed people at risk of receiving care that was not fully informed and posed a risk of incorrect information being shared with external healthcare professionals. This was raised with the provider who told us they would review all care plans to ensure they were up to date and relevant.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidableharmand neglect. The provider did not share concerns quickly and appropriately.

Staff we spoke with understood how to recognise potential safeguarding concerns and what action to take to report and escalate appropriately. However, we found multiple documented incidents that had not been shared to relevant partners such as, Care Quality Commission.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service and found where needed, people had DoLS authorisations in place.

However, MCA assessments were not always completed and, where assessments had been undertaken, they did not consistently evidence how decisions regarding a person's capacity had been reached.

The service maintained a DoLS tracker; however, this was not always accurate or effective in providing management oversight. For example, some people remained recorded as having an authorised DoLS despite the authorisation having expired. Although expiry dates had been recorded, the status continued to state 'authorised' rather than reflecting that a further application was pending. This meant there was a lack of clarity regarding which people were currently subject to a valid legal authorisation.

We also found that conditions attached to DoLS authorisations were not consistently reflected within people's care plans. As a result, there was no clear system to ensure staff were aware of, and acted in accordance with, the conditions imposed. This also made it difficult for managers to monitor compliance and assure themselves that the requirements of the authorisations were being met.

This meant people were at risk of having restrictions in place unlawfully.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Management kept a clinical risk dashboard which was regularly updated and provided them with an overview of people’s known risks. However, we identified some concerns with risk management.

Risk assessments and care plans were in place, however we found some contained incomplete, contradictory or incorrect information which placed people at risk of receiving inappropriate care. For example, there was inconsistencies documented regarding the frequency of blood sugar checks and there were no specific care plans for people who were on anti-coagulants.

Not all people had risk assessments in place associated with their care and support needs, or environment. This placed people at risk of harm and unlawful deprivations of their liberty. For example, we found a restriction across the home for people to have alarms on their room doors. Consent, capacity assessments or risk assessments had not been completed.

The provider 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 found cables and wires were on people’s beds and loose wires were near people’s pillows which posed a risk of harm. These concerns had not been identified by the provider on their environmental checks.

Some bathrooms were being used as storage and were still accessible to people which was a potential risk of injury or confusion.

The provider was receptive to our feedback and acted upon the concerns raised. They acknowledged the improvements required and demonstrated a commitment to people to improve the safety of the service.

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.

There were enough staff available to support people safely and meet their needs. During our assessment, staff were visible throughout the home and responded promptly when people required assistance. People and relatives spoke positively about staffing levels and the support provided. One relative told us, “There are always carers in the lounge and corridor, so if [family member] needs anything the carers are there very quickly to assist them. Residents are never left alone in the lounge.”

Staff told us they worked well together to ensure people's needs were met and that care was delivered safely. However, some staff described occasions when staffing felt more pressured, particularly during nights and weekends. One staff member said, “While essential care and safety are always maintained, nights and weekends can feel more challenging due to reduced staffing layers. During these times, any unexpected incident or resident emergency can quickly stretch our capacity.” We also identified some gaps in recruitment records. Despite this, there was no evidence people experienced avoidable delays in receiving care or support.

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.

The registered manager completed regular infection control checks to ensure proper procedures were followed and the home was clean.

We observed, and relatives confirmed, staff wore personal protective equipment (PPE) appropriately. A relative told us, “They wear all PPE for personal care and change it when coming out of each room.”

The kitchen was clean and well maintained. Since our last visit the food standards agency had completed a visit and had rated the service 5 on the 29 May 2026 meaning hygiene standards were very good.

We identified several concerns relating to medicines management. Some medicines, including topical creams and prescribed liquid medicines, did not have opening dates recorded. This meant staff could not be assured medicines remained within their recommended period of use once opened.

Where people received medicines covertly, this was not clearly identified on their Medicines Administration Records (MARs), although relevant information was available elsewhere within the care records. This increased the risk that staff may not have immediate access to important information relating to the administration of medicines. We raised this with the provider during the assessment and action was taken promptly to address the issue.

We also found some medicines, including prescribed creams and nutritional supplements, were not stored appropriately, which posed a potential risk to their safe management. In addition, there were inconsistencies in the recording of transdermal patch administration. Accurate recording of patch locations is important to reduce the risk of skin irritation and ensure medicines are administered effectively.

Despite these concerns, the management of controlled drugs was safe, with records completed in line with best practice. We also observed staff administering medicines in a kind, respectful and patient manner, supporting people appropriately and ensuring they received their medicines as prescribed.

These findings demonstrated that whilst people generally received their medicines as intended, systems and processes for medicines management were not always robust and required improvement.