Ashdown House

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.

We assessed only one quality statement during this assessment for the key question of caring. People and their relatives gave positive feedback about the care staff at Ashdown House. During our site visit we observed staff responding to people when they were able to, to minimise any discomfort, concern or distress. However, during busy periods of the day, we observed staff were not always available to respond to or anticipate people’s needs.

We identified a breach of the legal regulations in relation to good governance. The provider failed to have effective systems in place to assess, monitor and improve the quality and safety of the service. Systems to assess and monitor medicines, risk management, infection prevention and control and the environment safety had not identified or effectively addressed the concerns found during the assessment. Not all staff felt they could speak openly and did not always feel their voices were heard. Staff had received training in equality and diversity, and we saw evidence of some workforce inequality being addressed by the registered manager. Professionals visiting the home spoke positively about the service, the staff, and said people had access to healthcare support if required. The leaders acknowledged the feedback given by the inspector and took some action during the assessment to address the concerns found.