Ash Cottage

Incidents and accidents were not analysed for trends and themes to help reduce future occurrences and lessons learnt processes were not always being shared amongst the staff team. Staff lacked knowledge of DoLS (Deprivation of Liberty Safeguards), and the safeguarding policy did not contain important contact information to guide staff. Risks to people were not being managed well and not all staff were aware of people’s specialised tailored diets. Behaviour charts were not being completed accurately which meant we could not be assured distressed behaviours were being managed well. We found concerns relating to the environment and fire safety that had not been addressed. Concerns had been raised in relation to staffing levels and we found gaps in staff knowledge in relation to training. Not all medicines were being managed safely. People were moved between services safely and staff knew the process should they suspect abuse.

People and relatives were not involved in the care planning process and people were at high risk of choking due to being given inappropriate diets. Dietician plans were not being followed, and people were at risk of malnutrition. Concerns were raised in relation to staff communication and tools for monitoring people were not robust. People were not being supported with their oral care needs. A range of consent forms were in place and people were being supported by a physiotherapist to improve their health and wellbeing.

Activities were not person-centred and records of activities did not evidence people were involved in regular meaningful activity. This was a concern at our last inspection. Staff did not always react when people asked for assistance and relatives raised concerns in relation to staff communication barriers. Staff told us they were treated well.

Care plans held conflicting information which would confuse the reader and concerns were raised about missing laundry. Confidential information was not kept secure and not all relatives felt they were kept informed of people’s needs. We identified concerns in relation to the building which was not always safe, and staff had not completed training in end-of-life care provision. Referrals were being made to healthcare professionals as required and the staff team worked well together.

Governance systems were not robust. Concerns were shared to the leaders of this service, and no action had been taken. A range of audits were in place; however, they did not identify the concerns found during our assessment. Where concerns were identified, there was no evidence they had been actioned. Records were not always accurate and at times contradictory and not all professionals felt they were kept updated. Staff understood the term freedom to speak up and felt the registered manager was approachable. Staff praised the culture of the service and felt they worked well as a staff team.

The provider was in breach of the legal regulation relating to person-centred care, safe care and treatment, staffing and the governance of this service.

In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward. We have asked the provider for an action plan in response to the concerns found at this assessment.