Ashill Lodge Care 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

People in the service were not safe. There were several concerns we had identified on our on-site inspections and found 3 breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 these were Safe care and treatment, Meeting Nutritional and Hydration needs and Staffing. There was incorrect information recorded in care plans that could put people at higher risk or harm if followed. There were people at risk of being malnourished with no actions taken to protect and support them, people following incorrect diets which could affect their health and inadequate training standards and staffing levels at night, this has previously been a concern on historic inspections. There was poor risk management and concerns around the safety of the environment.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We could only speak to a small number of people living within the service as lot of people had advanced dementia and this impacted their understanding of what we were asking. We spoke to relatives of people within the service and they all said they knew how to raise concerns and they felt able to raise concerns but there was a mix of responses of whether these concerns had been addressed or not. Some of the concerns that had been addressed people felt the actions were ineffective and the issues hadn’t been resolved.

We spoke to staff and leaders in the service we asked if they discuss lessons learnt following incidents and we had a mixed response. A lot of the staff stated that they do discuss lessons learnt from incidents within the service regularly in staff meetings. Some staff we spoke with raised concerns that they don’t always feel listened too when they’ve raised concerns of poor practice within the service. All staff were aware of the whistleblowing policy.

We reviewed the services complaints log and all complaints had been dealt with and acted upon. However the service failed to identify any lessons learnt from these complaints to prevent them from reoccurring. We reviewed the services lessons learnt and they were to a poor standard and hadn’t identified any lessons learnt from accidents or incidents that had occurred in the service apart from 1. This was the same for Duty of candour incidents, there were only 2 incidents recorded. This contradicted what had been submitted to us in notifiable incidents where there have been several situations that have been recorded as applying the Duty of Candour but haven’t been recorded on their own logs. This doesn’t assure us that the service has a positive culture of openness and honesty and that safety events are investigated and reported thoroughly.

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 spoke to people in the service, and they didn’t always feel safe and supported with their mobility and this was echoed from relatives. They didn’t feel people were supported with their meals appropriately or that they followed the correct diet. Some Relatives felt they weren’t always informed when a person had an accident within the service and this didn’t leave them feeling reassured, people felt risks weren’t always assessed appropriately. One relative had raised their own safeguarding concerns following an accident. Some relatives had no concerns.

We weren’t assured staff had adequate knowledge with regards to safeguarding. The staff had completed safeguarding training. However, when asked how they safeguarded people, the majority of the staff responded “they would report concerns” but didn’t specify types of concerns they would report. They couldn’t explain when they would raise concerns with other agencies. We asked staff about their knowledge of the Mental Capacity Act, Best Interests decisions and Deprivation of Liberty Safeguards. There was a clear lack of knowledge around this. Majority of staff couldn’t explain what Deprivation of Liberty Safeguards meant. When we asked about their understanding of the Mental Capacity Act the most common response was “making decision in people’s best interest” they couldn’t explain the 5 principles when applying the Act and this didn’t assure us that staff had a good understanding to enable them to support people with day to day decision making and this could impact on peoples human rights.

We observed several safeguarding concerns that could put people at risk within the service. Restrictive practice was observed, we brought this to the Registers Persons attention, and they undertook their own investigation. Fire equipment that was last serviced in 2021 and a fire door that didn’t close. Incontinence products were stored on top of people’s wardrobes this was a health and safety concern but also undignified to people living in the service. An electrical fly zapper that was within reach in a communal area this posed a risk to people living with Dementia. On both onsite visits electric bed handsets were observed that they had exposed wiring and there was evidence that they had been repaired previously. There were wires from sensor mats left on the floor in people’s rooms and some leading into corridors which posed tripping hazards and the back of sensor mats had batteries exposed which increases the risk of harm for people living with dementia. The concerns were brought to the services attention, and they were acted on promptly. However, we were not assured due to reattending site and finding similar concerns within a short period. We found products used to clean peoples dentures left out in a room where people living with dementia have access to it. If they ingest this it could cause serious harm. However this was quickly removed when we made the registered manager aware.

We identified concerns of the services safeguarding systems, processes and practices. The processes were not robust as we had identified incidents that had occured within the service that met the threshold for safeguarding referrals and CQC notifications to be submitted and they were not. There were incidents were appropriate practices weren’t followed and the service had carried out investigations around safeguarding concerns prior to notifying and seeking advice from the local safeguarding team. This resulted in putting people at continued risk of harm for longer periods, there were no reports completed following the concerns raised to evidence an investigation was carried out, conclusions were reached and lessons were learnt from incidents.

People didn’t always feel they were supported to manage risks. One person we spoke with didn’t feel staff were able to support them with their mobility needs when they moved to the service, and it took the staff a while to be able to support them. Relatives didn’t always feel people were supported and encouraged to manage risks, they felt they weren’t encouraged to mobilise where possible or manage choking risks as advised. There was a mixed response from relatives on whether families felt they were kept up to date. Some felt they were while others felt they weren’t and would often find things out from staff when visiting the service.

When we spoke to the staff in the service about involving people to manage risks and asked for some examples on how this was achieved. There was only a couple of staff that could assure us. Some staff could identify risks within the service, but not unique to people in the service and how they were supported to manage them risks. When we asked of any altercations between people within the service and how these risks were handled; majority of the staff stated they would separate them and offer them a cup of tea. This didn’t reassure us that they knew the people and their needs appropriately and what could potentially trigger these incidents or how they were resolved effectively.

We observed restrictive practice that the service hadn’t risk assessed appropriately and could prevent people who are independently mobile from walking freely around the service. Staff did not always follow peoples risk assessments appropriately and people were found; cared for in bed attempting to eat their meals lying down and they were not supported to maintain a safe posture. People were not always following the correct diet that they had been advised to have from relevant healthcare professionals. This was noted on both onsite assessments. The service have since trained staff to be aware of the correct diets people should be on and are working with them the ensure this is being followed.

We reviewed several care records and a lot of these had conflicting information recorded in them or they had not been risk assessed appropriately and this didn’t give a true reflection of the risks posed. We reviewed food charts that evidenced people weren’t following the diets they should have been and the process that the service followed to capture what people had eaten and drank within the service wasn’t accurate. Half of the people within the service were at a medium risk or higher of becoming malnourished, the service had failed to act on all of risks identified and escalate to the relevant healthcare professional. The service have since put appropriate referrals through for these people.

We were not assured the environment was safe. When we arrived at the service we were not asked for any Identification or to sign in to evidence we were in the building. When we brought this to the Registered Persons attention, they also didn’t request for us to sign in. We checked the staffs signing in sheet and this wasn’t being completed appropriately either. When we attended the site on another occasion we were asked to sign in and on a review of paperwork could see that visitors were asked to sign in. However staff still failed to sign in when they are in the building. In the event of a fire or security breach the service wouldn’t be able to identify who is in and out of the building. Throughout the service there was a lot of information recorded on whiteboards, we didn’t feel these we robust measures to keep staff informed of people’s needs within the service, especially the kitchen environment. items could easily be wiped off and this could lead to someone not having a meal or not having the correct meal. The conservatory within the service was being used as storage. When we returned to the service the Conservatory was being cleared out.

We found a lot of the checks that were in place were not robust, They weren’t clear on what safety checks were being carried out and didn’t assure us that they had a clear oversight of the safety of the environment and this was confirmed through observations we found on the day. A lot of their processes were tick boxes and didn’t record what it was the service was checking so they couldn’t be assured that the environment was fully safe. The service had thermostatic mixing Valves (TMVs) installed on to their taps to prevent the temperature exceeding 44 degrees to reduce the risk of scalding. People within the service had access to these areas and when checked some exceeded 44 degrees and when we asked the service for evidence of their checks on the TMVs. They were unable to provide them. Since we carried out our assessment the service has started to use a new system that covers their maintenance/cleaning processes to ensure they are more robust however we cannot be certain on how this has been embedded or assess its true effectiveness at this early stage.

People felt most of the staff were kind and caring, but sometimes staff whose first language was not English would speak in other languages and this would make them feel uncomfortable. These findings were raised with the provider. The person didn’t feel there was sufficient staff on due to the length of time it takes them to answer their call bell. We spoke to relatives and there was a mixed response. Some relatives felt there was sufficient staff on especially downstairs while other relatives felt there wasn’t enough staff on and wouldn’t see any while they visited the service. This was the same for answering the door or the telephone when they rang. Relatives said they weren’t informed of staff changes within the service but the staff they had met when they visited were "nice and friendly".

We spoke to the staff in the service about the levels of staffing and there was a mixed response. Some staff felt there was sufficient staff on whereas others felt they were ok until an incident occurred within the service, and they were then impacted from this. However, reviewing the dependency of peoples needs in the service to the staffing levels we were not assured there were adequate especially at nighttime to ensure that people consistently received adequate and safe care. Although all staff had received a supervision most staff hadn’t had an appraisal. We spoke to some staff about specific training to enable them to carry out their job role adequately and support their development and they said they hadn’t been offered additional training to enable them to do this.

When we attended site, we arrived out of hours due to previous concerns of staffing levels through the night. We arrived early morning, There was 2 night staff on and another staff member that had started at 6am and supported until 8am, before going in to another job role within the service. We were told there was an on call person if required but they could be up to 30 minutes away. There were several people within the service that required support from 2 or more staff members to meet their needs. This meant that there was no other staff in the service having oversight over the rest of environment while these people were having the support they required. This was unsafe and put people at risk. We took urgent enforcement action around this and advised the provider to urgently review the needs of the people within the service to their staffing levels. The provider immediately implemented an additional person at night, however it was noted from previous inspections to be historical concerns being re-raised. We observed staff were not always following the uniform policy and no change of clothes between roles. This is also an infection control concern but the provider had taken action on this concern

We reviewed some staffs HR records and we found that they were not robust and safe recruitment practices were not always followed. There were gaps in employment checks and inadequate Risk assessments carried out and this could put people at risk within the service. There were gaps within the training and staff weren’t offered specific training to meet individuals needs within the service, Diabetes, Dysphagia and Stoma training were some examples of additional training requirements needed within the service. There were concerns around basic training not been sufficient, an inadequate number of staff that had completed food hygiene level 2 training and an insufficient number of staff trained to be fire marshals that didn’t cover a 24 hour period within the service. Apart from medicine competencies there were no other competencies carried out within the service, so we were not assured that staff were assessed on their ability to carry out their role effectively. There was a poor level of personal development in the service and at the time of the assessment the manager and team leader were the only individuals working towards an accredited qualification. Supervisions were carried out regularly within the service but it was not evident that staff had appraisals within the setting.

Generally, people within the service were happy with the standard of cleaning and they always saw staff wear PPE. most of the relatives we spoke with raised no concerns with the level of cleaning and saw staff wearing PPE but they hadn’t noticed if the environment had ever been decorated. A couple of relatives raised concerns about the cleanliness of the environment mainly the dining room.

Staff could explain to us how they handled infectious outbreaks following correct protocol; however we were not assured effective Infection control measures were imbedded within the team. Throughout our assessment we identified several chairs that required cleaning and replacing in the service as well as equipment and these weren’t identified by any of the staff or escalated within the service.

We observed the cleanliness of the environment and found several areas to be dirty and not well-maintained. There were chair covers that were visibly dirty and stained. Equipment used to transfer people was dirty and these had been recorded on the day that they were checked and clean and this was not to be the case, when we returned to the service, they were still visibly dirty. Chairs in the service were worn and had tears in them that could harbour bacteria. Bedding that was very thin and worn and we also found a room with stained bedding. When we first arrived at the service, we noticed a lot of food and stains on the floor, however these were cleaned up throughout the day.

Infection control processes were not robust, cleaning schedules did not record what had been cleaned. they were just a tick box to state it had been done. It did not assure us what had been cleaned in the environment. Infection control audits were carried out, but they lacked basic information like the date that they were completed. Where issues were noted on the audit there was no evidence to show they had been actioned. They were not recorded on the improvement plan. The Service has since amended its cleaning schedules.

Staff interacted with people kindly and provided support to people when medicines were administered. However, we found that care plans did not contain sufficient information for staff to support people with their complex needs. For example, we looked at care plans for people with diabetes, which contained incorrect and non-person-centred information. This meant that these people would not be managed correctly placing them at risk of harm. Person centred guidance was not always in place to support people to have their ‘when required’ (PRN) medicines and outcomes from this were not always assessed and recorded to ensure they were effective. We saw one person who had been prescribed a PRN sedative had been administered this daily to help them sleep. However, other techniques to support this persons sleep hygiene had not been explored. The daily use of a sedative placed them at risk of increased side effects such as falls. We highlighted this on the inspection and a plan was put in place by the visiting health care professional to reduce the amount of sedative taken by this person. There were no tools available at the home to assess people who were unable to communicate when they were in pain. In addition, staff did not always follow care plans to regularly monitor bowels for people who were at risk of constipation. This meant that there was a risk people would not receive appropriate treatment when they needed it. We asked relatives if people within the service had regular reviews with the GP about their health conditions or if they were actively involved in their care and majority of relatives, we spoke with felt they weren’t or that they weren’t aware if the GP was involved.

There was a weekly visit from a healthcare professional to review people and when staff escalated concerns. Staff received medicines training and were regularly assessed as competent. However, staff did not always know how to support individuals when they became distressed. There were processes in place to report and investigate medicines related incidents, but we were told that there had not been any errors.

Medicines were stored correctly, and room and fridge temperatures were monitored correctly. However, improvements were required in the security of the medicines, which were highlighted during the inspection. People were given their medicines on time. However, we saw one person who had not received their medicine for nine days. This had not been escalated immediately. People that were on anti-coagulant medication were identified to have no additional checks carried out on them People’s allergies were accurately recorded. When medicines were to be crushed to support administration to people, pharmaceutical advice was in place to ensure that this was carried out safely. Staff did not always document when topical creams had been applied. Therefore, the service could not be assured that this had been carried out according to prescriber’s instructions. A medicines policies and processes were in place. However, staff had not followed the process to escalate to the GP when a person has missed their medicine for nine days as it was not available.