Ashchurch View

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 remained Good.

This meant people were safe and protected from avoidable harm.

This service scored 72 (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 investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People and staff were encouraged and supported to raise concerns. They felt confident they would be treated with compassion and understanding, and not blamed, or treated negatively if they raised a concern.

There were policies in place to support organisational learning and actions. Daily, and sometimes twice daily meetings were held with the senior nurses to address any concerns including feedback from staff, people and relatives to ensure continuous improvement The registered manager met their requirements under Duty of Candour and acknowledged when things went wrong. This was documented in the complaint’s investigations.

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.

Safety policies and processes were aligned with other key partners who were involved in people’s care journey to enable consistency of safe care and shared learning to drive improvement. For example, people’s needs were assessed before they moved into the service and individual care plans were created to guide staff on how to support people and meet their needs. People’s health conditions were documented, and they were supported to access services from a range of professionals, including specialist nurses and dieticians.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve it. 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.

People were supported to understand safeguarding, what being safe means to them, and how to raise concerns when they don’t feel safe, or when they have concerns about the safety of other people.

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 a procedure called 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. We found there were 3 people in the service subject to a DoLS authorisation, the service had submitted DoLS applications for people where restrictive practices had been identified and were awaiting local authority authorisation. To mitigate risks to people, the provider had completed mental capacity assessments and implemented clear staff guidelines within care records. The provider demonstrated a consistent approach to the least restrictive care. For example, doors leading outside to the enclosed garden were always open during nice weather and people living upstairs had access to multiple large balconies.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs which was safe, supportive and enabled people to do the things which mattered to them.

Individual risks to people were assessed, and people were involved in this process as much as possible. People understood the risks relating to them and what they can do to keep themselves safe. There was a balanced and proportionate approach to risk which supports people and respects the choices they make about their care. Where appropriate, people were encouraged to take carefully managed risks to live a fulfilled and meaningful life. For example, one person was at high risk of isolation. Their care plan detailed how they were involved in considering new ideas of things they may like to do outside of their room. This meant they were supported to reduce their isolation.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

There were effective arrangements to monitor the safety and upkeep of facilities, premises and equipment. There were clear roles and responsibilities for the safe management of facilities, equipment and premises. The service had recently completed a planned refurbishment, and all areas of the service had been upgraded and improved with new furniture, fixtures and decoration.

The provider did not always make sure there were enough staff on the night shift.

Staff and people, we spoke to told us they had concerns about the staffing levels, especially at night. Staff told us, “There aren't enough staff. I think there have been times when there has been potential for danger. Night ratios are not good” and “We are at bare bones, and it can get dangerous. I think the nights certainly.” People told us, “The atmosphere in here at the moment is of everybody feeling rushed. So much to do and so few staff” and “Answering call bells is very debateable; depends on what job they are doing. There’s only 1 of them.” We observed during the day, on one of the communities, there was only 1 member of staff for 7 service users. When we checked this against the dependency tool, the tool stated the area only required 0.8% of a staff member. The dependency tool indicated this was in line with safe ratios however staff feedback did not corroborate this. This did not give us assurances the dependency tool was adequate to ensure service user needs were met. We observed on day 1 of the inspection, before the day staff started, there was only 1 care staff on each of the communities alongside 1 nurse for each floor who was administering medicines. We observed people who were ready to get up for breakfast, however with only 1 care staff, some people could not be supported with personal care or to be assisted out of bed. While we did not observe any service users were unsafe, they were not always supported in a person-led way due to staffing constrictions on night shifts.

During both days of the inspection, we observed on the smaller community where there was 1 member of staff. This meant people had to wait for their call bell to be answered as there was only 1 staff member to answer the call bells.

Staff recruitment files were not always in line with current guidelines as some records did not contain full employment histories or did not have gaps in employment explored. Some information was missing or recorded in a way which made it difficult to understand. The registered manager undertook a comprehensive review of all staff files immediately after our onsite assessment and we are assured all missing documents were completed.

Staff completed required training, and staff told us they had access to the learning and support required to carry out their roles. 

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.

Staff had received appropriate training and there were clear roles and responsibilities around infection prevention and control. Staff were trained and understand their role and responsibilities for maintaining high standards of cleanliness and hygiene in the service, including hand hygiene.

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Accurate, up-to-date information about people’s medicines was available, particularly when they moved between health and care settings, in line with current national guidance. People received medicines on time and as prescribed. People told us, “I need medications every so many hours. Staff speak to you about it… they help me because sometimes I can’t handle them on my own.”