Ashlee Residential 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 requires improvement. At this assessment the rating has improved to good. This meant people were safe and protected from avoidable harm.

This service scored 66 (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 safety concerns, reported incidents appropriately, and ensured that learning from these events informed ongoing improvements.

People using the service and their relatives understood how to raise concerns or make a complaint and were familiar with the complaint’s procedure. One relative said, “If I had any concerns I would speak to the registered manager. I know they would sort it for me.” The provider had systems for managing complaints and safety issues. The registered manager maintained oversight of all incidents to identify trends and implement actions to reduce risks.

Staff were supported to record and report incidents through clear processes. The registered manager promoted openness through an open‑door policy and regular team meetings, where accidents, incidents, and opportunities for improvement were routinely discussed.
 

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.

Staff followed established procedures to support effective handovers when people were admitted to hospital. Relevant information about each person’s needs was shared with paramedics and hospital staff to maintain consistent and safe care.

The team worked with healthcare professionals, including GPs and specialist practitioners, to monitor people’s health conditions and respond promptly to any changes in their support needs.

Where people had diagnosed health conditions, risk assessments guided staff on how to support them safely. The provider remained responsive to people’s changing needs and made referrals to healthcare professionals when required.

The provider engaged with people, their relatives and healthcare partners to understand what safety meant to them and how best to achieve it. Staff focused on improving people’s lives while upholding their right to live free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. Concerns were shared promptly and appropriately with relevant professionals.

Staff were trained in safeguarding, understood local procedures, and how to recognise and reporting concerns. People felt they received safe care. Staff prioritised people’s rights and safety while supporting their quality of life.

Potential safeguarding incidents were thoroughly investigated and reported to the local authority and the Care Quality Commission, helping to maintain people’s safety and wellbeing.

The Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards were applied to ensure decisions were made in people’s best interests. People at Ashlee Residential Care Home did not experience unnecessary restrictions.

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

We observed staff working safely and helping people with any equipment they used in a safe manner. Staff confirmed they received training to support people to move safely using equipment. Records we reviewed also confirmed this.

Staff were kept informed about any risks and changes through regular handovers and updated care plans. Risks associated with people’s health care conditions were discussed with them.

The provider took a holistic approach to understanding and managing risk. Staff delivered safe, personalised care that supported people to live in a way that was meaningful to them.

Risks related to people’s health conditions were discussed with them. Staff were kept up to date on risks and any changes through regular handovers and updated care plans.

The provider effectively identified and managed environmental risks. Equipment, facilities and technology supported the delivery of safe care. Staff confirmed that systems were in place to manage risks and promote a culture of safety.

Regular health and safety audits showed that potential risks were monitored and areas for refurbishment or repair were recorded. The refurbishment of the home was ongoing at the time of our assessment. An action plan was in place but not all actions required had target dates, this meant we could not be assured how long this work would take to complete. Some relatives told us that they felt the refurbishment was taking too long and made the home appear untidy. We saw the conservatory was being used a storeroom for furniture from the provider’s neighbouring home, which was also under refurbishment. The doors from the conservatory into the home and to the garden were accessible.

The provider ensured there were sufficient numbers of qualified and experienced staff who received appropriate support, supervision and ongoing development. Staff worked effectively as a team to deliver safe, person‑centred care.

Staffing levels were organised to meet people’s needs. People told us there were enough staff available and that they received timely support. One person said, “There are staff around to help me, they are always on hand.” We observed staff regularly checking on people and responding promptly when assistance was required.

People and their relatives reported that staffing levels were sufficient to meet their needs. Staff demonstrated confidence in their roles and a clear understanding of their responsibilities. They also confirmed they received ongoing training and regular supervision, which they described as supportive and beneficial.

Recruitment processes showed that all required pre‑employment checks had been completed to ensure suitable staff were appointed.

The provider assessed, managed, and mitigated infection risks, taking action to prevent and control potential spread and reporting concerns to relevant agencies when necessary. Staff adhered to infection prevention and control (IPC) procedures in line with current guidance.

During the inspection, we observed that staff were completing cleaning tasks and had undertaken training in infection prevention and control (IPC) and food safety. Staff also had access to appropriate personal protective equipment (PPE).

While no serious infection control concerns were identified, improvements were required to support staff in maintaining effective hygiene standards. The ongoing refurbishment in parts of the home, along with items being stored in areas not designated for storage, made it more difficult for staff to clean and maintain the environment effectively. For example, the staff toilet required refurbishment, and cracks in the plaster on the walls meant that surfaces could not be adequately cleaned.

The registered manager informed us following the inspection the refurbishment of the staff toilet facilities was scheduled to begin in early May 2026.

The provider ensured that medicines and treatments were safe and appropriate for each person’s needs, abilities, and preferences.

Records showed people generally received their medicines as prescribed, including appropriate pain relief. However, some improvements were needed in medicines management record keeping. The home was using a mix of electronic and paper systems, particularly for PRN (as required) medicines, which made reviews during medication rounds more difficult. Issues identified included a discrepancy in a PRN stock level and an unused medicine that had been prescribed six months earlier but not administered. Initially, staff were unsure why it had not been given, but it was later confirmed the medicine had been discontinued. This highlighted the need for better recording, auditing, and timely return of unused medicines. Following the assessment, the manager confirmed the service had stopped using electronic records and returned fully to paper-based systems.

Staff were trained and assessed as competent to administer medicines safely and understood the procedures for reporting and managing medication errors. During the inspection, staff were observed administering medicines calmly and, in a person‑centred manner, supporting people to take them in their preferred way and at their own pace.