Ashdown House

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 identified two breaches of the legal regulations in relation to safe care and treatment and staffing. Risks to people’s health and safety had not always been assessed or mitigated. People were not always protected from risks associated with infection prevention and control. Medicines were not always managed safely. Staff were not sufficiently trained. Systems and processes in place to maintain a safe environment were not always effective in identifying potential risks to people. People, their relatives and staff told us there was not always enough staff on shift. People told us they felt safe and safeguarding processes were in place and were being followed by staff and leaders. The registered manager conducted analysis of incidents and identified areas for improvement, staff told us this was shared with them. Further development was required to ensure staff fully understood and followed any changes to people’s care and support needs as a result.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and their relatives told us they felt confident the right action would be taken in the event of an accident or incident. One relative said, “Any incidents have been reported and have been dealt with promptly.”

Staff understood the procedure for when incidents occurred. A staff member said, “If someone has a fall our policy is to call emergency services, I would also check that the person can still move arms and legs and check where they are in pain.” Another staff member told us, “When a fall happens the senior on shift assess the resident checks for any injuries and arranges medical assistance.” Where the registered manager had conducted analysis of an incident and identified areas for improvement, staff told us this was shared with them. Further development was required to ensure staff fully understood and followed any changes to people’s care and support needs as a result. For example, one person suffered a fall which resulted in an increase of wellbeing checks to ensure their safety, however, records showed staff were not always completing this.

The registered manager conducted thorough analysis of incidents when they occurred, to identify the cause of the incident, review people’s care plans and risk assessment and to identify and share any lessons that could be learnt. However, in the absence of the registered manager, there was no process in place for incidents reported by staff to be reviewed, which meant potential increased risks to people or improvements would go unidentified.

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 and their relatives did not share any concerns about their safety at the service. People told us they would speak to the registered manager, care staff or their family if they were concerned about anything. Regular meetings took place for people to attend which gave people the opportunity to raise any concerns they had.

Staff had received training in safeguarding and understood their responsibilities in reporting safeguarding concerns. Staff told us they would report any concerns to the registered manager or director of the service.

During the assessment site visit we spent time observing staff interactions with people. We saw that staff treated people with kindness and respect.

The provider had a safeguarding policy in place which was accessible for staff. There were systems in place to report safeguarding concerns to the local authority. We checked whether the service was working within the principles of the Mental Capacity Act, and whether any conditions on authorisations to deprive a person of their liberty had the appropriate legal authority and were being met.

People’s relatives told us of their experience of risk management at the service. One relative said, “I am fully involved in care planning and any best interest decisions that have been made, following the last fall, equipment is in place my loved one is now hoisted, a crash mat, sensor mat and a new lower bed has been sourced”. Another relative told us, “My loved one came to Ashdown with a grade three pressure sore, with the care and support from Ashdown, this is now clear.” However, people’s risks were not always adequately assessed, managed or mitigated which placed people at risk of harm. For example, one person had been identified as at risk of leaving the service without staff support which placed the person at risk of harm. However, although risk measures had been put in place to reduce the risk of this happening, the assessment process had failed to ensure that external doors were in good repair and in working order which increased the risk of harm to the person.

Staff told us what they did to keep people safe and had access to people’s individual risk assessments. However, we were not assured that staff fully understood people’s individual risks and what was required of them to mitigate risks to people which placed people at potential risk of harm. For example, staff were required to check on a person every 30 minutes to ensure their safety, however, records showed staff did not always complete this in the required timescale.

During the assessment we saw equipment was in place to support people to manage risks, such as pressure relieving equipment for the risk of pressure sores and sensor equipment for the risk of falls. However, we observed that at times, staff were not always in the communal areas to supervise people, despite this being an identified risk measure for a person at risk of falls. We observed areas of the home that increased the risk of harm to people such as uneven flooring and trip hazards which increased the risk of falls to people. During the assessment, the provider took action to address this.

Processes to monitor how risks were being managed had not been effective in identifying or addressing shortfalls we found during the assessment. Where improvements in risk management had been identified, action taken to address this had not been effective in embedding and sustaining the required improvements. For example, in January and February 2024, the registered manager carried out an audit of care records and identified staff were not always recording they had carried out the identified risk measures. Actions to address this had not been effective or sustained.

People and their relatives felt the environment was suitable to their needs. However, we identified gaps in environmental safety checks which could impact people’s safety. For example, weekly fire door checks had not always taken place to ensure they were in good working order to prevent fire and smoke spread. Where fire door checks had taken place, this did not include a check of smoke seals and intumescent strips to ensure they were in good condition.

Staff had received fire awareness training and understood the actions they should take should a fire occur. Staff told us they checked moving and handling equipment before using it to ensure it is safe and in good working order. A member of staff said, “I check the slings to make sure there are no defect and that they have been serviced and in date.” There had been a recent change in maintenance staff which meant records had not always been kept up to date. There was a system in place for staff to report and record any maintenance issues. The provider informed us of their plans to refurbish the kitchen.

During the assessment, the laundry room door was observed to be unlocked on several occasions throughout the assessment site visits, with no staff member inside. It was later identified by the inspector that the door could not be locked by staff due to a faulty latch. The door to the kitchenette across from the laundry room was also unlocked with no staff inside and with easily accessible cleaning products which could be harmful to people if ingested. Stair gates used to reduce the risk of people gaining access to the stairs without staff support and to reduce the risk of falling down the stairs, were observed to be left open on several occasions throughout the site visit. This placed people at risk of harm from falling. We also found some fire doors that did not close fully when released.

The provider had systems and processes in place to maintain a safe environment, however, these were not always effective in identifying potential risks to people. For example, checks in place to reduce the risk of legionella in the water had not been completed effectively. Records showed weekly water flushes to reduce the risk of legionella had not been completed for a period of four weeks. Monthly sentinel water outlet temperature checks had been completed; however, the temperature recorded was lower than what was required to reduce the risk of legionella since March 2024. The provider’s systems had failed to identify this and take the required action. During the assessment and following feedback from the inspector, the provider took action to address this and test results showed there was no trace of legionella in the water system.

People were placed at risk of harm as not all staff had received training in moving and handling. Records showed staff had supported people with their moving and handling needs without the required training to do this safely. This had not been identified by the registered manager or provider and placed people at risk of harm. We received mixed feedback from people and their relatives in relation to staffing levels. A person told us, “I rang the buzzer, I didn’t know it was a changeover, and they take half an hour”. A relative said, “My love chooses to sit downstairs sometimes they are on their own for long periods, they prefer to sit downstairs as its quieter and there are reclining chairs and footstools, there has been an incident where I believe they were sat in the lounge till 1:00 am as they had to wait for two carers to be free to put them to bed”. Another relative said, “Staffing levels over the last few weeks have been sparse, this impacts on the residents the staff are doing their best”. Whilst another relative sad “There is always enough staff on duty when I visit, the staff are always willing to talk and do not appear to be rushed, they are well trained and I know most of them”.

Staff told us there wasn’t always enough staff on shift. A staff member said, “Sometimes they [people] have to wait a while, due to staffing levels.” Another staff member told us, “We need more staff, so someone is always on the floor. Sometimes I walk into dining area and there is no one there. It depends on who you’ve got in. It’s really tough sometimes.” Staff told us that staffing levels impacted people’s choice. A staff member said, “They [leaders] want us to get as many people [as possible] into their pyjamas before night staff come in, but we’re 24/7 so I don’t know why it has to be like that. And it takes away the choice for the residents.” Other staff members told us, “Some residents are not ready for bed at 6pm or 8pm – this is done to appease staff not to help residents.” and “Night staff get residents up before breakfast is even ready.” Staff told us they felt further improvement was required with their training as most was completed online and in their own time. Staff told us the lack of staff impacted people’s social stimulation, particularly when there was no activities member of staff on shift, as the care staff do not have time to support people with social outings or activities. A member of staff told us an planned outing into the community had to be cancelled due to lack of staffing.

During the assessment site visits we observed staff responding to people’s call bells in a timely manner.

Improvements were required to ensure staff were deployed effectively to meet people's needs in a timely way. Leaders told us they had reduced staffing levels in the afternoon from four staff to three staff following feedback received from a visiting professional. This decision was not based on people’s dependency needs calculations which showed four staff was required to meet people’s needs. The training matrix viewed at the time of our site visit showed improvements were needed to increase the completion of staff training. Staff were recruited safely, and all pre-employment checks were in place. The service used agency staff to cover shortfalls and where agency staff were used, they received an induction to the service. Staff received supervision meetings and regular team meetings took place with staff. Positive behaviour management support training had been identified as a learning need for staff during a team meeting in May 2024. Whilst information and guidance had been provided by the registered manager to staff via email, formal training has not yet been provided. We will follow this up at our next assessment.

Most people and their relatives felt the environment was clean. However, our findings during the site visit meant that people were not always protected from the spread of infections. During a recent meeting with people, the registered manager was informed by a person that they experienced the toilets to be dirty, and they needed to clean up before they used the bathroom.

Staff had received training in infection prevention and control and understood the importance of using personal protective equipment, such as gloves, when required. Most staff we spoke with did not raise any concerns about the cleanliness of the home, however, one member of staff told us, “Some staff get taken off cleaning to help care staff then the cleaning gets left.” Another member of staff said, “I feel that hygiene is not as good as it should be, I feel the care home is not clean. Sometimes you go into the bathrooms/toilets and it’s filthy, there’s funny smells.”

During the site visit, the inspector observed several concerns with infection prevention and control. For example, the inspectors observed a shower and shower chair in a communal bathroom to be visibly dirty and in disrepair. The shower chair was unclean and was rusty in parts which meant it would not be able to be cleaned and sanitised effectively. The inspector observed some high touch point surfaces with damaged paintwork an increase risk of infection spreading due to the surface not being able to be cleaned effectively. During the assessment, the provider took action to address some of the concerns found by the inspector. This included a replacement of the shower chair.

Audits were being carried out by staff to ensure the risks of infection was minimised and a cleaning rota was in place that evidenced regular cleaning of the home took place. However, systems and processes in place for infection prevention and control had failed to identify the concerns found by inspectors during the site visit. The registered manager and provider had not identified the shortfalls found prior to the assessment which increased risks to people.

People and relatives did not share concerns about the management of their medicines. However, our findings during the assessment found that people were at risk of not receiving their medicines as prescribed. We reviewed medication administration records (MAR) for three people and found these did not correspond to the amount of medicine tablets remaining in the packet. This meant people had not taken or received their medicines as prescribed which placed people at risk of harm. This had not been identified by the registered manager or staff. People did not always have access to their medicines, if required. We found there was no staff at night assessed as competent to administer medicines. Therefore, if people required medicines such as pain relief at night, this would not be available to them.

Senior staff had received training in medicines administration and had been assessed as competent to administer medicines to people who required support. The registered manager had delegated tasks to senior members of staff to audit and monitor medicines management. The registered manager acknowledged they had not had a direct role in the monitoring of medicines in recent months. During the site visit, the inspector asked the registered manager to carry out an audit of medicines which resulted in a 38-point action plan to address the required improvements. This included record keeping and stock control.

Where systems and processes to monitor medicines had identified areas of improvement, action had not been taken effectively to address this as we continued to find shortfalls during the assessment. For example, audits carried out by staff in April, May and June 2024, found shortfalls including discrepancies with signatures and medicine counts. The provider carried out a visit to the service in March 2024 and noted several errors recorded and instructed the registered manager to carry out a further audit and training. Although shortfalls had been identified, limited action had been taken to address this and reduce risks to people.