Ashgrove Care Home - London

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.

The last rating for this key question was requires improvement. At this assessment the rating has remained 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 provider was previously in breach of a legal regulation relating to safe care and treatment. Improvements had been made, and the provider was no longer breaching this regulation. However, we identified areas where further improvements were needed to ensure people were always safe.

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.

Systems for monitoring and learning from some incidents were not always robust. Some people expressed their anxiety verbally and/or physically. When this happened, staff recorded the incidents. However, records of these were basic and did not provide the details needed to monitor, reassess and mitigate future incidents. The staff used charts designed to monitor the triggers and consequences of incidents. However, these charts were not used to develop or improve care planning and assessments. We discussed this with the registered manager who told us they would be working with staff to help improve these records.

The management team had tried to foster a culture where staff learnt from accidents and when things went wrong. There were systems for recording accidents. These were reviewed by managers so that action plans could be implemented. Relatives told us they were informed when things went wrong and were told how improvements were being made. Staff explained that they reflected on and discussed lessons learnt together.

Accidents and concerns were recorded on an electronic system which senior managers and the provider’s quality team had access to. They provided additional guidance and support when needed.

The provider supported people to experience safe transitions between services. Staff assessed people’s needs before they moved to the service to make sure they could provide appropriate care. They liaised closely with external professionals to monitor changes in people’s needs and conditions. They shared information with hospitals and healthcare professionals to make sure others understood how to care for and support people.

The provider had procedures designed to protect people from abuse and keep them safe. However, 2 people told us about experiences where staff had spoken to them in a way which meant they felt unsafe. We discussed this feedback with the registered manager so they could investigate what had happened and take action where needed. Most people and their relatives told us they felt safe. Their comments included, “It’s extremely safe and secure, I have no worries about safety”, “I’m happy, it is safe” and “If there was a problem I would speak to the manager, and they would deal with it.”

The staff undertook training about safeguarding adults and were able to tell us what they would do if they suspected someone was being abused. They demonstrated a good knowledge of this.

There was information for people using the service, visitors and staff about how to recognise and report abuse.

The provider had worked with other organisations, including the local safeguarding authority to investigate and respond to safeguarding concerns and to take action to protect people from harm.

The provider had requested legal authorisations where restrictions amounted to a deprivation of liberty for people who did not have the capacity to consent to these. Decisions about people’s care were made in their best interests and for their safety.

The risks to people’s safety and wellbeing had not always been assessed or planned for. Whilst staff had carried out risk assessments as part of care planning, these were sometimes incomplete and were often generalised rather than specifically about the individual.

For example, some people had been assessed as at high risk of falling. Risk assessments relating to this were not comprehensive enough. For some people, the assessments considered only environmental conditions and generic guidance, such as ensuring no hazards were situated in walkways. These assessments did not include information about people’s individual needs, such as health conditions, or cognition. We saw 1 person spent time walking in a type of footwear which presented an increased risk of falling. Staff explained this was their choice. However, this had not been considered in the person’s risk assessment. There was no evidence that alternatives had been discussed. Failure to ensure risks were assessed and planned for placed people at increased risk of harm. We discussed this with the management team. Following our visit, they sent us an action plan which outlined how they would improve these records.

Whilst records were not detailed enough, we found staff had good knowledge of how to mitigate risks and prevent falls.

People and their relatives told us they felt people were safely cared for and risks were managed. Their comments included, “There is no problem with safety. [Person] is well looked after and if there is an issue I speak with the manager” and “I think they manage [person’s] distress well.”

There were suitable fire safety systems which included individual evacuation plans, staff training and equipment to prevent, detect and contain fire. There were regular fire drills and staff were able to explain how they would respond in the event of an emergency.

The environment was not always safe. We identified some risks within the environment on the day of our visit. We discussed these concerns with the registered manager who took immediate action to rectify these.

At our last assessment of the service, we found that risks within the environment were not always managed in a safe way. We found improvements had been made and the provider was no longer breaching legal regulations.

The environment did not reflect best practice guidance for people living with dementia. There was limited signage and information to help people orientate themselves. The provider told us they had a plan to improve this, giving consideration to colour schemes, lighting and signage.

There were enough staff at the service, although the deployment of staff was not always effective in meeting people’s needs. For example, staff responsible for administering medicines were regularly called upon by other staff to complete unrelated tasks. This meant some people had to wait a long time for medicines and there was an increased risk of error due to staff being distracted.

People using the service and their relatives gave mixed feedback on whether staff were available to meet their needs. Some people told us staff did not answer call bells or requests for help in a timely way. However, other people told us their needs were promptly met.

We saw that whilst there were plenty of staff available throughout the day, they were often focussed on specific tasks and would not respond to requests for help from people. For example, 1 person could not reach their call bell. They asked a staff member for help, but instead of reaching the call bell and passing this to them, the member of staff delegated the task to another staff member who the person had to wait for. In other instances, we heard people asking staff questions or for assistance. The staff walking past did not interact with them or stop to help.

The registered manager told us they had ‘overrecruited’ staff, and that they had enough staff to flexibly cover sickness and absence without using any agency (temporary) staffing. Staff told us they felt there were enough of them, and they did not feel rushed or pressurised by staffing levels.

The provider had systems for recruiting and selecting staff. These ensured staff were suitable. New staff completed an induction, a range of training and had their competencies and skills assessed. They took part in regular training updates, received supervision and took part in annual appraisals of their work with line managers.

The building was clean, however we found some equipment needed further deep cleaning. We showed this to staff who addressed this.

At our last assessment of the service, we found systems for managing and preventing infection were not always robust. At this assessment, we found improvements had been made.

The provider employed domestic staff who followed schedules for cleaning. The kitchen had been awarded a 5-star food hygiene rating.

People using the service told us they felt the service was clean and they were happy with the laundry service. Their comments included, “My room gets cleaned twice a day”, “It is clean, I have certainly not noticed any problems” and “Everything is ok with the laundry.”

There was hand sanitiser available throughout the home. All bathrooms and toilets had handwash, paper towels and suitable systems for disposal of clinical waste. There was enough Personal Protective Equipment (PPE) for staff when this was needed. Staff undertook training about infection prevention and control. There were regular audits and checks on cleanliness.

Medicines were not always administered in a timely way. This meant some people did not receive their medicines at the times the prescribers had intended. This was monitored and the timing of subsequent doses were adjusted to ensure there were sufficient gaps between doses. Staff ensured there were no adverse effects.

Some people were prescribed medicines to be administered ‘when required’ (PRN). Guidance to support staff to understand when this needed to be administered was in place. However, this information was not always detailed enough about individual needs. For example, some people were unable to verbally express pain. For these people, there was not enough clear information for staff about when to administer higher or lower doses. When PRN medicines were administered, there were inconsistent records of the outcomes from this. Therefore, it was not clear if the medicines had the intended effect.

Medicines including controlled drugs (medicines requiring additional security measures due to their risk of misuse) were stored safely and securely.

Care plans had comprehensive information about people’s medicines, including information about medicines prescribed to manage people’s diabetes and epilepsy.

Some people were administered medicines covertly (disguised in food or drink). We found that required assessments were completed including Mental Capacity Assessments and Best interests’ decision meetings had taken place, including obtaining pharmaceutical advice to ensure that medicines were administered safely.

Medicines related audits were conducted regularly and action plans were created for any issues identified. Staff followed processes to report medicines related errors. Incidents were appropriately investigated, and lessons learned were shared with the wider team to support improvement.

Staff felt supported in administering medicines and they had received regular medicines training and competency checks.