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 that people were protected from abuse and avoidable harm. At our last assessment we rated this key question inadequate. At this assessment the rating has changed to 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. At out last assessment there was no accident and incident analysis, and lessons were not learnt when things went wrong. At this assessment the management team had taken proactive steps to ensure a comprehensive system was in place to demonstrate lessons learned with a clear process of analysing safety events. This process included a summary of where and when incidents took place, the impact on people, and a root cause analysis to identify trends and patterns. Appropriate actions were taken to ensure issues were minimised.

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. We found staff and leaders made appropriate referrals to external professionals and staff followed their guidance. The care planning system was able to produce an emergency pack which would be used to pass on relevant information to healthcare professionals such as the hospital.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. 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. The management team had worked closely with the local safeguarding authority to ensure previous concerns were addressed. Staff told us they understood the safeguarding process and would take appropriate actions if they suspected abuse. Staff were confident the management team would act swiftly to protect people from the risk of abuse.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place, when needed, to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. The manager maintained a record of DoLS and care plans included information about mental capacity.

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. Risks associated with people’s care had been identified and managed to keep people safe. Since our last assessment, care plans and risk assessments had been reviewed and reflected people’s current needs. Risks such as choking, moving and handling, pressure care and malnutrition, were identified and clear plans in place to ensure people received the appropriate support to minimise risks occurring.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Since our last assessment the provider had taken action to improve the environment. For example, new floor covering had been laid where it was required, and some decoration had been completed. Fire safety actions have been completed, and picture signage was in place. People had updated personal emergency evacuation plans in place, which were available in a grab bag in the main entrance of the home.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. We observed staff interacting with people and found there were sufficient numbers of staff available to meet people’s needs. Staff were deployed effectively and worked well as a team to ensure people received care in a timely way. Staff told us they felt supported by the management team. One staff member said, “We have supervisions and appraisals, and I feel supported by my managers.” Some staff had not completed all mandatory training; however, the management team had previously identified this and were taking appropriate actions to address compliance. During our assessment the training statistics had improved to 80 percent compliance. At our last assessment we identified gaps in some application forms. The registered manager told us the recruitment process had been amended and any gaps in employment were now discussed at interview stage and recorded in the interview notes.

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. We found improvements had been made since our last inspection and the service was predominantly clean. However, we identified some outstanding issues such as the domestic store needed a lock as the cleaning trolley was stored in there with cleaning products accessible, store cupboards needed tidying and new coverings to shelves to enable them to be cleaned effectively. Attention was required to the freezers sited on the first floor as they were in need of defrosting and the fridge had a heavy build-up of debris from milk cartons and required cleaning. These issues were actioned on the day of our assessment.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Since our last assessment the management team had taken actions to address the shortfalls in medicine management. Temperatures were now taken of medicine storage facilities and medication provided in a patch form were administered appropriately and body maps showed patch rotation. People who were prescribed medicines on an as and when required basis, often referred to as PRN, had protocols in place to ensure they were administered correctly. We observed the senior carer administering medicines safely. One staff member said, “We receive training in medicine management, and our competencies are checked.”