Ashill Lodge 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 inadequate. At this assessment the rating has changed to requires improvement.

This meant although the service had improved, some aspects of the service were not always safe. There was an increased risk that people could be harmed.

The service remained in breach of legal regulation in relation to people’s safe care and treatment around peoples identified risks and how these were managed. However, previously the provider was in breach around the staffing. This inspection identified they were no longer in breach in this area.

This service scored 53 (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 always have a proactive and positive culture of safety based on openness and honesty.

We found compliments and complaints did not consistently identify lessons learnt. This was an area we noted on the last inspection and although there had been some improvements it was not a consistent approach. The provider acknowledged that their improvements should have been more robust with lessons learnt within the service and have since updated their auditing tool However, the service could evidence compliments and complaints were discussed regularly in staff meetings and there was evidence of other lessons learnt, and these were shared with the team.

The service did evidence safety alerts were received, reviewed and acted upon. Accidents and incidents were analysed to identify any trends or themes and actions were taken where appropriate.

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.

We found in-depth pre-admission assessments were conducted prior to people moving into the service, this was communicated clearly to the staff and they had an understanding of people’s care and support needs prior to moving into the service. Referrals were submitted to relevant healthcare professionals if required on admission and when people’s needs changed.

A staff member told us, “If someone moves into the care home, the manager will tell us about the person, then we need to read the care plan. We try and talk to them and learn about them, what they like to do and find out everything about them.”

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. The provider did not always share concerns quickly and appropriately. For example, the service did not raise safeguarding referrals when they had concerns for a person who was at risk of harm due to falling and where one fall resulted in a head injury. We raised this is with the provider who acknowledged this was an oversight and they reported the incident retrospectively and confirmed they would update their policy around falls.

We reviewed the services safeguarding policy, this was unclear around the process staff should follow. It did not state the actions staff should take depending on the type of abuse identified. The service had a children’s safeguarding policy in place, however It failed to record how to report concerns to the local authority and did not have the local authorities contact details recorded.

Some staff we spoke with could not tell us different types of abuse and we were not assured they could identify or report concerns to protect people from harm. One staff member had worked in the service for a considerable time and was in a senior role, however; another staff member was within 6 months of employment. When we raised this with the provider, they arranged re-training and competencies for the staff involved.

Where people lacked capacity and their freedom was deprived in order to protect them the service ensured they had appropriate deprivation of liberty safeguards applications in place where applicable and those that had been granted were reviewed and included within peoples care plans.

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. Care notes did not evidence people’s risks were managed and mitigated. Staff did not record consistently people at risk of choking or aspiration followed the correct modified diet for all foods. This was a historical concern that was identified on the last inspection and although some action had been taken to address this shortfall it did not cover all food that people consumed.

A person had a history of aspiration pneumonia and their care plan recorded they had to be sat at a 90-degree angle for all meals and to sit up for at least 30 minutes following their meal to ensure their risk of aspiration is mitigated. Staff did not evidence in their care notes that this was being managed. One person was assessed of high risk of their skin breaking down, staff did not record that they had checked their skin to monitor it for any concerns. This could put people at risk of harm. We found people had risk assessments in place and they did not always identify the risks posed and others risk assessments failed to assess the risks fully. We observed staff support a person with their mobility and staff failed to ensure that the individual was transferred the shortest distance possible. This increased the risk to the person.

We spoke with the provider about these concerns, and they had worked with staff around appropriate manual handling and staff had started to record the correct consistency of all food people consumed.

The provider did not always detect and control potential risks in the care environment. They did not always make sure facilities supported the delivery of safe care. We found environmental risk assessments had not fully assessed the risks posed. Stair risk assessments did not include adequate lighting, anti-slip stair treads and people using the stair gates at the top and bottom of the stairs. Laundry risk assessment recorded cardboard being stored near a vent instead of removal of it. The risk assessments included falls and trips but did not include spillages.

The fire procedure was not clear on what was classed as a small fire in the service and what staff should do. The service had asbestos within parts of the building, the asbestos survey had not been reviewed by the provider since 2018. The provider could not evidence contractors were aware of the asbestos in the building or the fire procedures.Following feedback, the provider actioned this, contractors had started to sign in the contractor’s log. The provider had arranged a new asbestos survey to be carried out and they had reviewed their fire policy and environmental risk assessments.

However, the environment had improved since the last inspection. The environment was safe and secure; furniture was fixed to the walls appropriately. Windows restrictors were in place. Maintenance records were complete. Staff had regular fire drills carried out and could inform us of the action they would take in the event of a fire.

The provider did not always make sure there were enough qualified, skilled and experienced staff. We found there were gaps in staffs’ knowledge and understanding around safeguarding people. Staff did not consistently follow best practice with supporting people with their mobility and maintaining Infection prevention control standards.

However, we raised these concerns with the provider and they arranged additional training and competencies to be conducted. We observed there was an adequate number of staff to meet people’s needs, people living in the service agreed, 1 person told us, “we don't have to wait long” and a relative told us, “during the week very good staffing, at weekends not so much, I still feel there is enough staff though.” Staff received regular supervisions and had an annual appraisal conducted. We reviewed HR records and appropriate recruitment checks were conducted on staff.

The provider did not always assess or manage the risk of infection. We observed staff not following infection control processes consistently, a staff member was wearing nail varnish which can prevent effective hand hygiene. Another staff member had long hair that was not tied back and we reviewed photos of the environment this was noted on other occasions involving the same staff member, this can prevent effective hygiene standards. We raised this with the provider, and they addressed the concerns with staff. We observed unclean urine bottles stored in a communal toilet and a person’s ensuite in their bedroom. The provider raised this with staff and carried out additionally checks of the environment.

However, the rest of the environment was clean and tidy. People were happy with the cleanliness of the service. A person told us “yes they come and clean my room and they do it daily as they know I like it clean” and another person told us “oh yeah very good, always cleaning my room”

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. People received their medication when they should. Audits identified any errors and staff could tell us the processes for managing medication, 1 staff member said, “medication training is very thorough, and I think my last medication competency was November.” Staff could explain the medications that people took and why. People told us staff told them the medication they took and why, 1 person said, “I've not had any problems, they tell me about my medication.”