Ashton Court 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 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 changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to safe care and treatment, safeguarding, infection prevention and control and medicines management.

This service scored 34 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

An accident and incident analysis had been completed but this did not identify trends and patterns to minimise future risks. Some daily notes reflected accidents and incidents which had occurred but these were not documented on accident forms and had not been included in the analysis. Therefore, the analysis was not a true reflection of the incidents which had occurred. There was no evidence of lessons learnt and discussions had not taken place with staff to enable them to learn from accidents and incidents and improve outcomes for people.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. Staff and leaders did not always make appropriate referrals to healthcare professionals to ensure people received safe care. For example, contact had not been made with professionals following a series of falls to ensure staff took action to mitigate risks. The care planning system had the ability to produce an emergency pack which would be used to pass on relevant information to healthcare professionals such as the hospital. However, care plans were not always a reflection of people’s needs and this meant, in some instances, the information could be incorrect.

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, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately. We found safeguarding concerns which had not been reported in a timely way. This put people at risk of harm. Staff told us they understood the safeguarding process and said they would take action to report concerns.

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. Risks associated with people’s care had not always been identified or managed to ensure people received safe care. The risk assessments in place did not always reflect people’s current needs. For example, a person at risk of falling did not have a risk assessment in place to mitigate this risk. Another person’s care plan stated they required staff to assist them to reposition on a 2 hourly basis to prevent pressure care related issues and to maximise their comfort. We reviewed daily notes and found many occasions where repositioning had not been completed in line with their care plan and sometimes a delay of between 4 and 6.5 hours before repositioning was implemented. This presented a risk of pressure damage. Care plans lacked information regarding the safe use of equipment such as hoists. People’s care plans did not have instructions about the size or type of sling which should be used or the loop configuration required to assist people to mobilise safely. Some risk assessments showed actions taken to minimise risks but this was not consistent throughout the care plans and risk assessments, placing people at risk of significant harm.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care. We identified furniture not attached to walls, including a radiator cover, tall bookcase and wardrobes. There was a risk of these pieces of furniture toppling over onto people who were mobilising around the home. The provider took action to address these concerns. We found 1 person’s room situated on an upper level of the home had no window restrictors in place presenting a risk of falls from height. We identified bed rails in place where people had not been assessed for them and mattresses were ill-fitted with a significant gap between the end of the mattress and the head of the bed. This posed a risk of entrapment and potential injury. Personal emergency evacuation plans were in place and could be found in the emergency grab bag situated in the main porch area. However, this was initially difficult to find. The provider was in the process of addressing some concerns raised as part of a recent visit from the fire service. We found a storeroom cluttered with equipment and some fire doors propped open.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. Staff did not always work together well to provide safe care that met people’s individual needs. People and relatives told us there were sometime not enough staff. Relatives were concerned the lounge area was often left without staff presence. One relative said, “I think with all these people in this room [lounge] they [staff] should be around permanently to observe.” There was no evidence of first aid training being delivered as a practical session, it was provided as an online session. This presented a risk to people if staff were not able to respond safely to emergency situations. The provider had a recruitment policy in place which was used to employ suitable staff. However, we found gaps on application forms were not always followed up during the interview process. Staff told us they enjoyed working at the home and felt supported by the management team. One relative said, “I believe the staff know what they are doing [relating to skills and knowledge]”.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly. At our last inspection we recommend the provider took action to improve infection, prevention and control (IPC). At this inspection we found IPC had deteriorated. Many areas of the home were poorly maintained and not kept clean. For example, armchairs were dirty and in need of a deep clean. We identified a mattress which was heavily stained, toilet seat raisers which had not been cleaned effectively and there was a build-up of dust and debris behind the washing machines and dryer in the laundry. This put people at risk of cross infection. Following our first site visit the provider took action to address some of these concerns, however, on our second site visit we found only slight improvement.

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning about how they received their medicines safely. Protocols were in place for medicines prescribed on an ‘as and when’ required basis, often known as PRN. These protocols were not specific in identifying how people may present if they required their medicines. Temperatures were not taken of storage facilities where medicines were kept. One person was prescribed medication in the form of a patch but this was not rotated in line with recommendations. Stock balances for some boxed medicines did not tally with the medicine in stock. We raised these issues with the registered manager who took action to address them. People told us they received their medicines as prescribed. One person said, “I receive my medication regularly and see the doctor when he visits.”