Ashlett Dale Rest 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 requires improvement. At this assessment the rating has remained requires improvement. This meant people were not always safe and protected from avoidable harm.

The provider was in breach of legal regulation relating to staffing.

This service scored 50 (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 reported safety events. Processes needed to be improved to ensure lessons were learnt to continually identify and embed good practice.

Staff meetings were recorded, and staff confirmed these were used to share learning. However, there was limited evidence that management processes were robust enough to ensure adequate oversight of learning from incidents. For example, incident forms were written by staff following falls or other events. The incident forms contained a review section to be completed by management for monitoring themes and trends, including questions relating to whether the accident/incident was preventable; whether staff followed correct procedures; and had there been any further investigation, actions and outcomes. These sections were blank and the registered manager had no other recorded process. The registered manager informed us of the actions they were taking to address shortfalls we identified during the inspection.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

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.

Staff received training in safeguarding. Staff were confident that any safeguarding concerns they raised would be acted on by the registered manager. We saw evidence that recent safeguarding referrals had been made appropriately.

People did not always receive consistent support from staff to manage risks associated with their health and wellbeing. This was because risks were not always monitored and/or managed in a timely and effective way. There was a lack of clear and personalised records and lack of monitoring of follow up actions.

People had care plans and risk assessments for mobility and falls. However, these were not all up to date. One person’s assessment stated they had no falls in the last 12 months, but the daily care notes indicated they had 3 unwitnessed falls in the space of a week. Incident forms were completed by staff following these falls and signed off by management, but sections were left blank so we could not be assured actions were always taken to reduce risk of future falls. Other records such as weight monitoring and catheter changes were also not fully completed.

A person’s falls risk assessment stated they required staff supervision at all times to mitigate this risk. However, we observed a number of staff taking a break at the same time, leaving the person alone. This exposed the person to a risk of harm in the event of a fall.

There was not a robust system for following up health concerns. When staff had been unable to support a person to have a blood test, records showed they planned to follow up with the GP. However, no further action was taken despite the daily records indicating the person continued to have falls and show signs of confusion. Following the inspection, the registered manager confirmed the blood test had been completed.

Although we found some areas of concern, many relatives said they were happy with the service, with some confirming their involvement in care plans. The service had good working relationships with local community health teams and 2 health professionals told us the service worked together with them well. They visited regularly and staff would alert them if there were any concerns.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider did not have robust and safe recruitment practices to make sure that all staff are suitably experienced, competent and able to carry out their role. They did not always make sure staff received effective support, supervision and development.

Systems and procedures for recruiting new staff were not robust. We looked at records for 2 staff, which showed there was a lack of thorough and completed checks during the recruitment process. This included staff being allowed to work without a full Disclosure and Barring Service (DBS) being completed, a lack of appropriate risk assessment, references obtained from unsuitable sources that had not been verified, and an incomplete employment history.The registered manager told us staff were supervised whilst they were waiting for their full DBS to come through but could not produce any evidence of this in relation to 2 staff whose records we reviewed.

The registered manager told us staff were supervised whilst they were waiting for their full DBS to come through but could not produce any evidence of this in relation to 2 staff whose records we reviewed. The registered manager informed us of the actions they were taking to address this.

Staff received training and completion of this was monitored. The training record showed most staff were up to date with their training. Staff competency checks did not always take place or were not recorded.

There were sufficient staff deployed to provide people with the support they required. The staff rota included care staff, kitchen and cleaning staff, and activities staff.

People we spoke with were very positive about the staff and their ability to meet their needs. We also spoke with 2 health professionals who told us they “Always see quite a few staff around.” They said the registered manager and staff appeared to know people and understand their needs.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

There was some lack of sufficient individualised and personalised information within people’s medicines records. For example, insulin administration records lacked the name of insulin or target range. When required and variable dose protocols were not adequately personalised. Records lacked guidance about what to do where 2 medicines were available to treat the same condition. This exposed people to a risk of not receiving their medicines as prescribed.

Staff received on-line training in medicines. The registered manager told us there were 10 staff competency spot checks required, however there were no records of these. This meant the provider could not be assured staff had the required knowledge and skills to administer people’s medicines. The registered manager said they will design and implement these checks as soon as possible.