Ashby Lodge Residential 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.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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

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 did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse and avoidable harm. They did not always share concerns quickly and appropriately. We reviewed evidence confirming incidents of aggression between people had occurred in communal areas. Although incidents had been recorded, these had not been reported and shared with partners, and no steps had been taken to protect people. Since the recent management change, we confirmed appropriate referrals and involvement from partners had been initiated and we saw evidence of ongoing support to actively improve people’s lives and protect them from further incidents. The service had a recently reviewed safeguarding policy and staff had received safeguarding training and showed a good knowledge of safeguarding including identifying and reporting safeguarding concerns.

The provider did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe and supportive. We found risks were evident in the service regarding people with behaviours that challenged and although the provider was aware of the risks, they had not previously completed appropriate referrals and taken sufficient action to reduce and mitigate risks to people and staff. Staff had not previously been adequately supported with updated risk assessments and guidance to manage incidents of behaviour and keep other people living at the service safe. However, since the recent management change, we saw evidence of involvement of partners offering support and guidance to the service, reporting and recording of incidents to relevant agencies and updates to staff guidance and risk assessments to manage and mitigate risks.

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. The service had a maintenance person in post, and they told us they had recently, with support of the new registered manager, been provided with paperwork to record completed checks. However, there was no evidence of any profiling bed checks and bed rail checks completed. Only 1 recorded recent fire drill were available and no other fire drills prior to the most recent completed at the service were available for review, so were not assured fire drills were completed regularly at the service. However, the registered manager had an action plan that had identified the issues with planned dates to ensure these actions were completed in the near future.

The provider did not always make sure staff received effective support, supervision, appraisals and regular staff meetings. Some staff reported high management turnover with temporary managers impacting upon the running of the service. We found inconsistencies in the safe recruitment practises of the provider. Full employment history was not recorded and therefore gaps in employment were not explored. This was an area for improvement already identified by the registered manager, and a plan was in place to address it. The provider made sure there were enough qualified, skilled and experienced staff and a dependency tool was used to assess staffing levels. The staffing provided was in line with the staffing levels identified within the completed dependency tool.

The provider did not always assess or manage the risk of infection. Although the home was odour free and generally tidy, we found issues with the cleanliness is some areas of the home. Cleaning schedules had just recently been put in place. There were staff on shift tasked to complete cleaning tasks, but this did not cover the full week. The registered manager told us they were in the process of recruiting additional staff to this role. We observed staff bare below the elbow and wearing appropriate personal protective equipment (PPE). The provider had recently reviewed their infection prevention and control policy and were working on an external partner's ongoing action plan to drive improvements.

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