Ashcroft House - Leeds

⚠ People were not protected from risks because the provider had failed to identify or sufficiently plan for risks and guide staff on how to reduce and minimise these. This placed people at risk of significant harm. People were not protected from the risk of choking. There was no sufficiently detailed …

⚠ Medicines were not always administered safely and in line with the instructions of the prescriber. We found medicines which had been signed for but not given to people in a returns box which were due to be destroyed. Some people had not received their medicines for consecutive days. Staff responsible …

⚠ At the last inspection the service was rated requires improvement and the provider was told to make improvements in a number of areas. At this inspection we found the provider had not made improvements and the service had deteriorated in quality. Two people had come to harm and the provider …

⚠ People using the service were not protected from the risk of abuse. Staff had received training in safeguarding. However, we found an incident had occurred and none of the staff present reported this to the registered manager or made a safeguarding referral. This meant we were not assured that staff …

⚠ There were not enough staff to support people safely. People told us there were not enough staff to support them when they needed it. One person said, 'There is not enough staff and sometimes you can't find anybody and if there is two on you can't find anybody.' There were …

⚠ People at risk of malnutrition were not effectively supported to manage this risk. They were not weighed regularly, and we noted significant gaps of several months for people at risk of weight loss. One person who was underweight had not been weighed since September 2023. The hospital weighed this person …

⚠ People's needs were assessed when they came to live at the service. However, these were not always reassessed on an ongoing basis to monitor whether their needs were changing. Care plans did not reflect best practice guidance such as that provided by the National Institute of Health and Care Excellence …

⚠ People's individual needs were not met by the adaption, design and decoration of the premises. Many of the corridors were plain which made it was harder for people living with dementia to navigate around. There was nothing identifiable on many people's bedroom doors so they could identify their bedroom easily. …

⚠ Staff did not have a good understanding of the Mental Capacity Act and how they should apply this in their role. People were not always enabled to make choices according to their ability and to maintain control of their own lives. People told us staff did not always let them …

⚠ The service was not caring. Whilst some staff were intuitively caring, the provider and registered manager had allowed people to be continually exposed to the risks of poor and inappropriate care and had failed to take action to improve standards of care. This does not demonstrate a caring service. People …

⚠ People were not always supported to express their views and make decisions about their care. Care records did not consistently reflect people's thoughts, feelings or wishes on their care. Care records were not person centred enough and did not reflect people as individuals. There was not always evidence of people …

⚠ People's privacy, dignity and independence were not always respected and promoted. People and relatives told us there had been a long-term issue with the laundry which meant they did not receive their own clothes from the laundry and other people's clothes were put in their wardrobes and offered to them …

⚠ People were not supported as individuals, in line with their needs and preferences. Care records were not personalised to reflect people's diversity and individuality. Some preferences were included, but these were often limited and there was no information about people's routines or how they wished for their care to be …

⚠ The provider was not meeting the Accessible Information Standard. People's communication needs were not fully understood and supported. People's communication methods were not always recorded in their care records. Information was not adapted to ensure people could access it. People living with dementia were not always supported to make visual …

⚠ End of life care planning was not sufficiently detailed. For some people, no preferences were recorded. For other people who were in the end stages of their life, there was no information about the complex care they would require at this time to ensure they had a comfortable and pain …

⚠ People were not supported to maintain relationships, follow their interests, or take part in activities that were relevant to them. People were largely disengaged with little source of engagement or stimulation available. Care staff told us they did not have time to sit with people and engage with them, and …

⚠ The provider did not have a system in place to provide person-centred care that achieved good outcomes for people. The culture of the service was not open or positive. People were not supported to live their lives in the way they wanted. People were not consistently protected from the risks …

⚠ Quality assurance systems did not lead to continual improvement. A system of auditing was in place; however, it was ineffective because they did not always highlight where improvements were needed. Where areas for improvement had been identified, they had not always been addressed or sustained. The provider had been told …

⚠ Feedback was not consistently sought or acted upon. People and their relatives were given the opportunity to participate in a survey of their views and in meetings. However, meetings were not regularly carried out; meeting minutes were only available for 2 meetings since January 2023. People's feedback had not always …

⚠ The provider did not always work effectively in partnership with others. Where advice had been provided by external healthcare professionals, this did not always lead to changes in care planning for people and care delivery. The provider had been advised against admitting one person to the service by the local …