Ashdene, a supported living service for male ex-offenders and people at risk of homelessness, improved from Requires Improvement to Good following a focused inspection of Safe and Well-led key questions. The provider remediated previous breaches of Regulations 12 and 17, demonstrating robust risk management, safe medicines handling, and effective governance processes.
Strengths
· Risks associated with people's care were appropriately assessed and staff were knowledgeable about risk management, including criminal history considerations.
· Medicines were managed safely using an electronic medicines system with annual competency reviews.
· Governance processes were robust with audits completed at all levels of management and use of external auditors.
· Staff felt supported and comfortable raising concerns, with issues acted upon quickly.
· The service worked collaboratively with other health and social care professionals to provide effective care.
Quality-Statement breakdown (7)
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrong
Good
safe: Using medicines safelyGood
safe: Systems and processes to safeguard people from the risk of abuse; Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; Continuous learning and improving careGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Engaging and involving people using the service, the public and staff; Working in partnership with othersGood
Ashdene, a residential service for ex-offenders, was rated Good overall with Safe rated Requires Improvement due to a breach of Regulation 12 around medication fridge temperatures, an overfilled sharps bin and missing MAR signatures. Effective, Caring, Responsive and Well-led were all Good, with strong partnership working, person-centred care planning and effective leadership.
Concerns (5)
criticalMedication management: “the fridge had daily recordings of the fridge temperature, there were records of a maximum temperature of 21.8 degrees Celsius during January”
criticalMedication management: “the sharps bin in the dispensary was filled over the maximum fill line raising the risk of a needle stick injury to staff”
moderateRecord keeping: “there were seven missing signatures on the medication administration records (MARs)”
moderateRecord keeping: “One resident required that their blood sugar levels needed to be checked three times per day. The records of their blood sugars however did not show this was the case.”
minorCare planning: “We advised the registered manager that they needed to have a risk assessment in place for each person who lived at the home.”
Strengths
· Strong partnership working with Police, probation services and social services to support rehabilitation
· Person-centred care plans developed collaboratively with people, reviewed weekly with key workers
· Comprehensive and specialised staff training including reducing re-offending and self-harm awareness
· Robust recruitment processes including DBS checks and references
· Effective leadership with regular auditing, action plans and oversight by senior managers
Quality-Statement breakdown (15)
safe: The service did not always manage medicines safely.Requires improvement
safe: Staff demonstrated a thorough understanding of safeguarding people.Good
safe: The recruitment processes were safe and robust.Good
effective: Staff were well trained and competent.Good
effective: Staff were well supported and received regular supervisions and appraisals.Good
effective: People enjoyed a good range of home-cooked meals.Good
caring: Staff were kind, caring and considerate in the way they interacted with people.Good
caring: People were treated with dignity and respect.