Ash Grove

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

The provider had processes in place to ensure people were protected from risk of harm and abuse. Staff knew potential risks to people and how to report concerns. The provider had processes to learn from accidents and incidents to ensure learning took place to prevent them from happening again. The home was generally safe, though we identified that 1 window did not have a window restrictor on and some wardrobes were not secure to the wall. The provider took action to rectify these issues. Systems and processes in place ensured medicines were well managed and people received their medicines safely.

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’s feedback raised no concerns about learning culture. Relatives felt their loved ones were safe living at Ash Grove.

Learning and actions following safeguarding matters were addressed and discussed with staff to ensure the service improved and developed. The staff team had been through a challenging time with one staff telling us, “Back 6 months ago it was a toxic environment, it was geared up towards what the staff wanted, not what people needed or wanted.” However, with staff and management changes they (staff) felt things were improving.

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.

Although some relatives shared concerns in relation to the high usage of agency staff, no concerns were raised about their loved one’s safety. One relative said, “It's a great service. [Person’s name] is happy and safe.”

Staff had received training on how to recognise and report abuse. One staff member told us, “Management seems ok, I would be happy to approach [service manager name]. I think they would listen.”

Whilst we observed some improvements were required as reported on in safe environments, overall we observed the environment to be safe. People were not restricted from accessing communal areas such as the kitchen. Measures were in place to ensure this was safe for people. We observed people appeared relaxed with staff.

People’s feedback raised no concerns about safety. Risks relating to people were assessed. These included risks associated with the environment, mobility, eating and drinking. In addition, risk assessments were in place for people who chose to smoke.

Staff knew people well. Staff could recognise signs when people experienced emotional distress and anxious behaviours and knew how best to support them. People’s behaviour support plans set out preventative and reactive strategies for staff to follow to help keep people safe and enhance their well-being.

We observed staff that knew people’s individual needs. We saw how staff were able to effectively anticipate and manage situations. For example, to prevent people from becoming anxious and distressed. People were supported to access the community, and they were supported to do this with the correct numbers of staff to ensure peoples’ safety.

Relatives were on the whole positive about the safety of the environment. One relative said, “The home is safe.” Another relative told us, “[Person’s name] is safe and gets on with the others. [Person] would tell me if there was something they didn't like. I trust the service.” However, a further relative said, “Generally, the home is fine. Its calm and peaceful. Its clean and its safe. However, quite often we have arrived, pressed the doorbell and got no answer. Residents open the door, and anyone could walk into the home. We have to call out ‘anyone home’. Its more at weekends where there are less (permanent) staff and more agency.” We brought this to the attention of the operations manager to address. They told us they were not aware of this but would address this issue with staff in staff meetings.

We made observations of the service environment in relation to the safety of the environment. We observed one window did not have a window restrictor on and some wardrobes were not secure to the wall. We discussed this with the facilities manager who confirmed they had already identified these issues and they were on their action plan to address.

We spoke with 4 relatives about their family member’s experiences of receiving support and care. Relatives told us there had been a lot of staff who had left over the last few months. One relative told us, “We have one or two concerns with agency staff. I get the feeling the agency are not trained as well as the permanent staff.” Another relative said, “All the Mencap staff are fabulous. My issues are the number of agency staff who tend to be more at weekends.” A further relative commented, “They (staff) are really lovely. The only problem is it's a bit unsettling as members of staff have left and there are a lot of agency staff.”

Staff told us they had undertaken essential training to carry out their roles. A new member of staff told us how they were completing their induction and shadowing permanent staff before working on their own. Staff spoken with said they would benefit from having more of their own permanent staff. The management team told us they were working closely with the human resources manager to recruit more staff. They also explained how they had worked on the interview process. This included interview questions being specific to Ash Grove as previously interview questions were standardised.

We saw there were enough staff, including one-to-one support, for people to take part in activities in their home and to support people to take part in activities outside of their home. For example, to attend the day centre, go swimming and shopping. Whilst we observed positive interactions between people and staff and saw people approached and engaged with staff at all levels, we did observe 2 staff members physically support a person to stand up even though their care plan stated, “Needs minimal prompts to mobilise independently.” We shared this with the management team to address.

The provider had robust recruitment processes in place. We reviewed 2 staff recruitment files. Pre employment checks had been carried out to ensure staff were suitable to work with vulnerable people. This included references, obtaining proof of staff identity and DBS (Disclosure and Barring Service) checks. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Staff had undertaken relevant training to support people safely. Staff training was monitored. The operations manager and nominated individual were currently addressing the issue of eLearning modules not being marked as mandatory with the learning management system, though staff had received this training.

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.