Ashwood Rest 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

During this assessment we looked at 3 quality statements in the key question of safe. The overall rating for this key question combines scoring from quality statements we looked at during this assessment and quality statements scores in line with findings from our last inspection, where the service was rated good. We found that not all window restrictors were in line with requirements set out by the Health and Safety Executive’s guidance. The provider took immediate action in response and by the end of day 3 of the assessment site visit, work had been completed to ensure all window restrictors met requirements. Policies and procedures were in place to reduce risks related to fire, water and equipment. Effective risk assessments were in place for people’s health and medical conditions. However, risk assessments around the use of the stairs did not contain sufficient detail to reflect that all risk factors had been assessed or considered. The registered manager took immediate action to update risk assessments to ensure they were robust working documents which helped to minimise risks. The registered manager was developing processes around investigating and reflecting on incidents to look for trends, causes and ways to reduce risk of recurrence. These processes were still in development and the registered manager needed time to ensure these systems were working effectively.

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.

People gave positive feedback about the provider’s response to incidents and told us that they felt safe in the home. Comments included, “When I had a fall and the staff were brilliant at looking after me” Relatives told us the provider acted quickly and appropriately if their relatives had an accident to help ensure their safety. Comments included, “Staff rang me immediately [after relative had a fall]. [I was happy with] the way they [staff] looked after her. Now she has the fall mat and the bell to help her."

Staff told us how they reflected upon incidents, reviewed actions taken and made changes to people’s care in response. The registered manager had been developing systems to review incidents periodically to analyse underlying causes, trends and ways to reduce risk of recurrence.

Records of incidents and accidents did not always fully document the investigation and subsequent actions taken to reduce the risk of recurrence. The registered manager had recognised where improvements were needed and was developing processes to ensure all actions in response to incidents and accidents were recorded and associated care plans were updated. Although actions were not always well documented, we found through speaking to people, staff and the registered manager that the appropriate actions had been taken to escalate concerns to professionals in response to incidents, but it was just that records did not always reflect this. The registered manager had a service improvement plan in place. This was in line with recommendations from the local authority after a visit to the home. The plan included actions around medicines, The Mental Capacity Act 2005, staff training and responses to incidents. The registered manager had implemented improvements detailed in the action plan and was in process of ensuring changes were embedded and sustained.

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.

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

People told us they were involved in planning their care and managing risks. Their care plans included information on how to support people safely. People told us staff were always available to support them and they had appropriate equipment in place to promote their safety. Comments included, “I definitely feel safe living here. I have my [call] bell, I have a falls mat (to alert staff of a fall)” and, “[Staff member] is absolutely great, she is always there for everyone, if you need help she will always be willing.”

Staff were knowledgeable about people's individual needs and were able to explain how they supported them to maintain safety. The registered manager reviewed risk assessments and care plans on a regular basis. They had a good understanding of the level of needs which the service could accommodate, making referrals to professionals for additional support when people’s needs became complex. This helped to ensure people had appropriate levels of support, equipment and professional input in place. The registered manager quickly identified when people’s needs were changing, in order to plan pro-actively when they may need an alternative placement, such as nursing care. This helped to ensure that any necessary transitions to other services were planned well in advance to minimise the impact on people.

We observed that staff were vigilant and pro-active in providing support to people who were at high risk of falls or at risk when using the stairs. We observed that staff made regular welfare checks to people throughout the day, which helped to monitor their whereabouts and ensure their safety. We saw that staff checked moving and handling equipment before use, to help ensure it was in safe working order. When staff supported people to mobilise around the home, they were encouraging and patient, which helped people feel safe and comfortable. We observed staff supporting people to manage their health conditions as independently as possible. For example, one person, who had diabetes, independently monitored their blood sugar levels. We observed that staff would engage the person in conversation about daily blood sugar levels, which helped staff monitor their condition, whilst promoting the person’s independence.

People’s individual risk assessments for safety around the use of stairs did not always fully consider all risk factors or document how to reduce these risks. For example, risk assessments did not document that people had been assessed as being safe to use the stairs independently and how often this was reviewed. Risk assessments did not make a distinction between risks related to two different staircases. These posed different risks due to their layout and design, so specific detail would be needed to document how risks were assessed and reduced. After the 3rd day of assessment site visit, the registered manager sent us updated risk assessments, which were much more detailed and fully reflected all considerations associated with the risks around people using the stairs. Care plans around people’s medical and health, reflected guidance from external professionals and were regularly reviewed. Staff monitored people's wellbeing and changes in their health, which prompted timely referrals to other professionals for advice and guidance.

People and relatives felt the service was a safe and suitable place to live. They raised no concerns about safety and told us they felt reassured that staff were always available to help and assist. Comments included, “Yes, I consider that [my relative] is totally safe living here” and, “I do feel safe living here. If I ever need any help someone always comes to find out what I want."

The registered manager carefully considered the suitability of potential admissions to the service, specifically, in relation to safety around the stairs and when people wandered with purpose. This helped to ensure they only accepted new admissions for people suitable for the environment at the care home. The provider was very responsive to issues we highlighted around window restrictors not always fully meeting requirements set out by The Health and Safety Executive. This action demonstrated a responsive approach to feedback which helped to promote people’s safety. Staff had a good understanding of risks to individuals in relation to the service’s environment. They were able to tell us about the levels of support people needed to stay safe and explain how they monitored and reduced identified risks, such as the risk around using stairs.

On day 1 of the assessment site visit, we found that some window restrictors did not meet requirements set out by The Health and Safety Executive’s guidance. Specifically, some windows were fitted with restrictors that could be manually disengaged, as opposed to being disengaged using a key or special tool. By the 3rd day of the assessment site visit, the provider had completed a full audit of the windows and completed work to ensure suitable window restrictors were fitted. On day 2 of the assessment site visit, we observed the provider carrying out a fire evacuation drill. We observed that staff were calm and clear in their duties and confidently followed instructions set out in the provider’s evacuation procedure.

The registered manager completed regular environmental safety audits. However, these audits did not identify the issues which we found around window restrictors. Therefore, audits were not always effective in promoting the safety of the environment. An external company completed a fire risk assessment of the service in December 2023. The provider had completed a set of recommendations from this risk assessment, which had helped to improve fire safety at the service. People had personal evacuation plans in place, which detailed the support they would need to safely evacuate the building. This helped to ensure there were safe procedures for staff to follow in the event of an emergency. The provider completed regular checks and routine servicing of equipment such as, fire safety equipment, moving and handling equipment and passenger lifts. This helped to ensure this equipment was in good working order and safe to use. There were policies and procedures in place to manage water safety in relation to legionnaires' disease. This includedS2 risk assessments and testing of water by an external company and checks completed by staff to help monitor water safety.

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

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.