Ash Villa

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

We assessed 3 quality statements in the safe key question and found areas of good practice. The scores for these areas have been combined with scores based on the rating from the last inspection, which was good. The assessment of these areas indicated areas of good practice since the last inspection, therefore our rating for the key question remains good. People felt safe living at Ash Villa. Staff understood their duty to protect people from abuse and knew how and when to report any concerns. When concerns had been raised, the registered manager reported these to the relevant agencies and worked proactively with them, to make sure timely action was taken to safeguard people from further risk. Safety risks to people were managed well. People’s needs were assessed and reviewed to ensure they were protected from the risk of avoidable harm. People told us they were involved in making decisions about how they wished to be supported to stay safe. There were enough staff to support people safely. Staff completed training to meet people’s needs. Staff were supported through regular team meetings and supervisions. Staff were recruited safely which protected people from receiving care and support from unsuitable staff.

This service scored 75 (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.

People told us they felt safe from abuse. One person said, “I feel safe and happy here, I have staff to talk to.” People felt confident to raise concerns about their safety and told us, “I would talk to staff especially [staff name].” People told us they had never felt unsafe living at the home and felt reassured staff were present to help them when needed. There were no unlawful restrictions imposed on people. People were free to complete their own routines and live their lives as they wished. Some people would be at risk if they did not have continuous supervision and control, where this was the case, we saw staff had applied the suitable Deprivation of Liberty Safeguards. These safeguards ensure people who cannot consent to their care arrangements in a care home or hospital are protected if those arrangements deprive them of their liberty.

The registered manager understood how to respond to allegations of abuse. They had a clear process of how to investigate and keep people safe. The registered manager displayed a passionate and dedicated attitude to ensuring people were protected from the risk of abuse. The registered manager gave us multiple examples of incidents they would report and action they had taken in the past to protect people from the risk of harm. Staff understood how to support people’s relationships. Staff gave us an example of completing assessments regarding sexual safety and relationships. Staff understood how to respond to allegations of abuse. Staff told us that they had no concerns, but if they did, they were confident the management team would act appropriately. Incidents and lessons learnt were discussed at each team meeting to ensure staff were aware of what action had been taken to reduce the risk of recurrence. Staff knew where to find the safeguarding policy. They were aware of the policy and knew how to follow it to keep people safe from potential abuse.

We saw people and staff had positive relationships. There was an open culture of communication and we saw no evidence that people were at risk or fearful of the staff team. Staff acted appropriately when a person started becoming distressed using redirection and distraction techniques to divert a possible safeguarding incident involving people living at the service.

Safeguarding concerns were reported in a timely manner to the relevant authority, and action was taken to reduce any ongoing risks to people whilst waiting for an outcome from the safeguarding team. Lessons learnt were shared with the staff team to reduce the risk of recurrence. If an allegation of abuse was made, there were appropriate policies in place to guide staff. Records showed incidents were investigated and referred to the local authority safeguarding team if needed. Staff received training in safeguarding and were supported to discuss any learning from safeguarding incidents in their preferred forum, such as individual supervisions or at regular team meetings. People were supported to keep themselves safe when they went out. A person at risk of exploitation had been extensively supported to increase their independence whilst also ensuring they made safe choices to ensure they were protected from abuse. There was a clear plan in place to support the person.

People told us that they were able to communicate their needs, to receive the support they wanted. One person we spoke with told us; staff supported them to go out to the shops safely and to make hot drinks independently. People told us that staff understood their needs well and offered support to keep them safe. One person said, “Staff are kind, and they help me by talking with me” and another person said, “Staff know me, and they always ask me if they don’t know anything.”

Staff knew people’s needs well and how to support any associated risks safely. There was a clear approach to supporting people’s risks in a person centred and least restrictive way. Staff told us people were supported to take positives risk aligned with their needs and aspirations. A staff member gave us an example of a person who wanted to spend time outside away from others, staff supported the person to do this in a safe way to meet their needs. Staff gave us several examples of how they supported people to reduce episodes of anxiety. The registered manager told us, “We know people well and so we know if someone is going to become upset, we have developed tools and strategies to support people to reduce the times they become anxious and ultimately to make sure they are safe.” Staff promoted people’s independence through positive risk taking. Staff told us how they supported a person to become more independent, with the goal set for the person to live independently. They referred the person to other social care professionals in order to gain specific assessments to ensure their safety was maintained.

We saw people were supported safely. We observed staff to anticipate many risks to people where they were unable to self-assess. We saw where people needed one-to-one support from staff due to risks, staff were always present to ensure they and other people living at Ash Villa were safe.

People had detailed person-centred care plans in place. Ash Villa were in the process of moving over to an electronic system. New risk assessments were being completed with people’s key workers to ensure accurate information was documented by staff who knew people well. Risks were assessed and risk reduction measures detailed. For example, positive behaviour support plans were in place where people were at risk of becoming distressed or anxious. This meant staff had information to de-escalate situations when they arose. Each person had an individual personal emergency evacuation plan in place. This meant staff and emergency services had accurate information in the event of an emergency. People’s communication needs were documented. Some people living at Ash Villa could not communicate verbally, communication methods were documented to ensure staff had accurate information to communicate with people using their preferred format. Some staff at the service were completing Makaton training to strengthen their communication. Staff kept clear records on what support they provided to people. This allowed for people’s progress to be monitored and any changes or improvements highlighted.

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

People told us there were always enough staff and any needs were responded to quickly. One person said, “There are enough staff day and night, I am keen to go to bed at nighttime and staff help me.” People told us staff treated them kindly and they felt safe as a result. A person said, “The staff are kind and helpful. I am not scared here.”

We spoke with 4 members of staff during the inspection and requested feedback from 4 others following our visit to Ash Villa. Staff raised no concerns regarding staffing levels during our assessment. The registered manager told us they had reviewed staffing levels and had recently increased them in line with the dependency tool in place. The registered manager told us they used agency staff occasionally due to vacancies; agency staff were fully inducted and where possible they booked staff who had worked at Ash Villa before. Staff received training to ensure they carried out their duties safely. The registered manager told us they had support from the provider to ensure they could carry out their management duties effectively. Staff meetings and supervisions were completed to ensure staff were supported.

We observed there were enough staff to provide support to people safely. Staff were deployed effectively around the building, to provide timely care and support. We observed staff to treat people kindly and with respect. We saw where people needed one-to-one support this was in place throughout the day.

There were clear processes to ensure there were enough staff. The provider had used a dependency tool to assess how many staff were required to meet people’s needs. Record’s we reviewed detailed staff had been allocated to work in line with the dependency tool. Staff were recruited and inducted safely. Processes ensured necessary checks were completed prior to staff starting at Ash Villa. This included reference checks, proof of identity as well as Disclosure and Barring Service (DBS) checks. A DBS check is a way for employers to check an employee criminal record, to help decide whether they are a suitable person to work for them. This protected people from receiving support from unsuitable staff.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

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