Ashfields

Ashfields is a purpose built single-storey residential care home providing personal care to up to 44 people. The service provides support to older people some of whom may be living with dementia. At the time of our inspection there were 40 people using the service.

People’s experience of using this service and what we found

People did not receive their medicines as prescribed. This was because some medicines were out of stock in the service and therefore could not be administered. Some people were refusing their medicines and staff had not taken appropriate actions in response to this. Further concerns relating to the management of medicines including recording practices were also identified.

Risk assessments and care plans did not always effectively identify and address risk. We identified concerns relating to the management of people’s nutrition and hydration needs, skin care and falls. We observed some instances where personal protective equipment was not being worn correctly to protect people from the risk of infection.

Governance systems in place had not been effective in identifying and improving the quality of the service. Records in respect to people’s care were not always accurate and contemporaneous.

Following our inspection visit the regional director provided an update of initial actions they were taking and assurances that they were addressing the concerns identified.

Staff knew how to raise safeguarding concerns and felt confident to do so. However, concerns and incidents relating to medicines management had not been identified or reported as a safeguarding concern, as specified by local safeguarding guidance.

The environment was clean and hygienic. People and staff were taking part in regular COVID-19 testing. People were supported to maintain important relationships, and this included ensuring family and friends could visit the service. People were supported by enough staff who had been recruited safely. Where incidents had occurred, the registered manager had oversight of these. Incidents were discussed with people, relatives and staff, to facilitate any lessons needing to be learnt.

People and relatives were engaged in the service and feedback was sought from them in a range of ways. The registered manager was approachable and supportive. People were supported by a cohesive and caring staff team. There was a positive and pleasant atmosphere. Staff interacted with people in a person-centred and respectful manner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 01 June 2018).

Why we inspected

The inspection was prompted in part due to concerns received about the management of medicines, the management of risks in relation to eating and drinking enough, record keeping and governance. A decision was made for us to inspect and examine those risks.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively. This included checking the provider was meeting COVID-19 vaccination requirements.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to safe care and treatment and good governance at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice:

The service had built a visiting pod in the front garden for visitors to see their relatives who lived in the service. Due to its position the visitors did not need to access the home.

The people who lived in the service had their own visiting plans and risk assessments which included details of who they would like to have visit or keep in contact with, how this was best achieved and how to support their wellbeing.

Managers, staff and relatives had access to a coronavirus helpline to answer queries, give advice and guidance to support them during the COVID-19 pandemic.

There were detailed, easy to follow procedures in place for standards of cleaning and laundry management to guide staff during potential or confirmed cases of COVID-19.

The service provides residential care in a purpose built building for up to 44 older people, the majority of whom are living with dementia. There were 39 people living in the service when we inspected on 19 March 2018. This was an unannounced comprehensive inspection.

We last inspected this service in November 2016 and rated the service as required improvement. During that inspection, we found that, although effective systems were in place to monitor the quality and safety of the care provided in most areas, the provider had not effectively assessed and monitored that people received enough to drink to meet their individual needs. There were not always sufficient staff on duty to support people; this had an impact at mealtimes, which meant that sometimes people had to wait for assistance. Risks in relation to people developing a pressure ulcer required improvement. This was because people assessed as being at a high of developing a pressure ulcer were observed as not using specialist equipment to protect them, people were seen not using their pressure relieving cushion. This meant that the systems in place to assess and monitor the quality of care provided were not effective.

Following the last inspection, we asked the provider to complete an action plan telling us what improvements they would make to bring the service to at least Good. During this inspection on 19 March 2018, we found that improvements had been made to meet the requirements to help ensure that people received a good service.

Ashfields has a newly registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The new registered manager took up their post in December 2017 shortly after the previous manager left in that month.

People who spoke with us and relatives said they believed their relatives were safe and well cared for.

There were systems in place that provided guidance for staff on how to safeguard the people who used the service from the potential risk of abuse. Staff understood their roles and responsibilities in keeping people safe. There were processes in place to ensure the safety of the people who used the service. These included risk assessments, which identified how risks to people were minimised.

There were sufficient numbers of trained and well supported staff to keep people safe and to meet their needs. Where people required assistance to take their medicines there were arrangements in place to provide this support safely, following best practice guidelines.

Both the registered manager and the staff understood their obligations under the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). The registered manager knew how to make a referral if required. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service support this practice.

People were supported to eat and drink enough to maintain a balanced diet. They were also supported to maintain good health and access healthcare services.

There were arrangements in place to make sure the service was kept clean and hygienic.

We saw many examples of positive and caring interactions between the staff and people living in the service. People were able to express their views and staff listened to what they said and took action to ensure their decisions were acted on. Staff protected people’s privacy and dignity.

People received care that was personalised and responsive to their assessed needs. The service listened to people’s experiences, concerns and complaints. Staff took steps to investigate complaints and to make any changes needed.

People, their relatives and the staff, told us that the registered manager had made positive changes in the service and that they were open and had good management skills. There were systems in place to monitor the quality of service offered people.

Further information is in the detailed findings below.

Ashfields is a service that provides accommodation and personal care for up to 44 people. During the inspection visit, there were 38 people living within the home, most of whom were living with dementia.

There was a registered manager employed at the home. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the home is run.

At the last inspection on 13 January 2015, we asked the provider to take action to make improvements to the management of people’s medicines, assisting people to eat and drink enough to meet their needs and to their processes to monitor the quality of care provided. At this inspection, we found that some improvements had been made. However, although effective systems were in place to monitor the quality and safety of the care provided in most areas, the provider had not effectively assessed and monitored that people received enough to drink to meet their individual needs. You can see what action we have told the provider to take at the back of the full version of this report.

The provider has assessed the number of staff required to provide people with safe care that met their needs. However, the required number had not always been reached resulting in less staff working on some days than there should have been. This placed people at risk of not receiving care in a timely manner or care that met their needs. The provider had recognised this and was making improvements within this area.

Risks to people’s safety had been assessed and in most cases, actions had been taken to reduce any risks that had been identified. However, risks in relation to people developing a pressure ulcer required improvement.

Systems were in place to reduce the risk of people experiencing abuse. Risks in relation to the premises had been assessed and the home was well maintained. Equipment that people used had been tested to make sure it was safe to use and people received their medicines when they needed them.

The staff were kind, caring and compassionate. They treated people with respect and upheld their dignity. They provided people with choice so they could make decisions about how they wanted to be cared for. People’s individual care needs had been assessed and they were encouraged to join in with a variety of different activities to enhance their wellbeing.

People had access to a good choice of freshly prepared meals and snacks. Staff sought advice from other healthcare professionals and acted in a timely manner when any concerns about people’s health had been identified.

The staff requested people’s consent before they provided them with care. Where people were not able to give consent, the staff made sure that they took any decisions they made on their behalf in the person’s best interests.

Staff had the necessary skills and knowledge to enable them to provide people with effective care. The registered manager monitored the completion of their training to make sure it was up to date and appropriate.

The provider had identified that they wanted to improve the quality of care being provided to people living in the home, the ultimate aim of which was to improve people’s quality of life and wellbeing. Improvements had commenced which involved staff receiving further training regarding supporting people living dementia and making changes to the environment.

We spoke with people who used the service, a relative and a number of staff. We reviewed six people's care records and charts and 10 staff records. We also reviewed a selection of other records in relation to accidents and injuries and audit results.

We used the evidence we collected during our inspection to answer five questions.

Is the service safe?

People told us that they felt safe and the staff we spoke with understood their responsibility in relation to safeguarding vulnerable adults. The provider had policies and procedures in place to help protect people from the risk of abuse.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. At the time of the inspection the trainee manager was in the process of submitting an application for a person assessed as requiring this safeguard. We noted that they were following the correct procedure in applying for this authorisation.

However, where people did not have the capacity to consent, the provider had not always acted in accordance with legal requirements. We found that not everyone, who may have needed to be, had been assessed in relation to their capacity to make day-to-day decisions. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to consent to care and support.

Generally, there were enough suitably qualified and experienced staff to meet the needs of the people who used the service. However, during our inspection we noted that the lounge, where people with more advanced dementia spent their time, was not staffed at all times during the day. We saw evidence that this put people at risk. The risks were in relation to people's immobility, unsafe mobility, not being able to change their own position and not meeting people's emotional needs. During one occasion when the lounge was not staffed, a person slid from their chair on to the floor. We also observed one person repeatedly calling out and asking why no 'nurses' were present in the room to help her. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to adequate staffing to ensure the needs of people are met.

There were effective procedures in place to manage and mitigate foreseeable emergencies. The staff we spoke with were aware of these procedures and told us that they knew what they should do in the event of an emergency.

Is the service effective?

We noted that nationally recognised screening tools were used including the assessment of people at risk from malnutrition and pressure ulcers. We noted that the results from these assessments adequately informed people's care plans. This included people being assisted to eat and drink, and people at risk of developing pressure ulcers, being positioned on air-flow beds and pressure relieving cushions. We saw evidence that sensors were used in people's individual rooms that alerted staff when people got out of bed. This meant that staff could attend to them in a timely manner. The trainee manager told us that the number of falls in people's rooms had reduced since the introduction of the sensors.

However, we noted that there were numerous gaps in people's records in relation to their repositioning, oral care, recording of fluid and diet intake and their weights. This meant that people could be at risk of deterioration because regular reviews of people's health and wellbeing were not being recorded. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to ensuring the welfare and safety of people using the service.

Is the service caring?

We could not speak with some of the people using the service because they had complex needs or communication difficulties which meant that they were not able to tell us their experiences. However, we noted that staff interacted positively with these people and used different means of non-verbal communication to try and ensure people's needs were being met. The people we did speak with told us that they were happy living in Ashfields. One person said, 'I have been here a long time and am very happy. The food is lovely and I get well looked after.' Another person said, 'It's wonderful here. The staff help me with everything and I have no complaints.'

During our inspection we observed staff, at all times, caring for and supporting people in a compassionate and respectful manner. Staff were patient at all times and took their time when assisting people. It was evident that the staff knew the needs of people well and gave person-centred care.

Is the service responsive?

We saw evidence that the service was generally responsive to people's social and emotional needs. There was some outstanding practice in relation to the activities available to people, including group and individual activities. The activities coordinators clearly matched activities and social interaction to meet the individual needs of people, and promoted people's inclusion in the community. This included assisting people to church and facilitating trips out. People's activity during the day was documented in detail including any changes in their mood and their communication and mobility needs.

Residents and relatives meetings took place every third month and there was an annual satisfaction survey for people to complete to determine their thoughts and comments about the service. We noted that people were positive about the service and relatives felt that their relations were well cared for.

The trainee manager told us that the management team had an 'open door' policy for people using the service and their relatives to enable them to raise any concerns or complaints. We noted that complaints were minimal. Complaints were appropriately documented and we saw evidence that they had been investigated and resolved.

Is the service well-led?

At the time of our inspection we spoke with the trainee manager as the registered manager was on leave. They told us that they were in a training position because the provider advocated succession planning to reduce the risk of a service being left without a registered manager if they chose to leave.

We observed a positive culture within the service. All of the staff we spoke with told us that they felt well supported and spoke positively about the management team. We noted that there were regular staff meetings and that staff were encouraged to raise comments in order to help improve the quality of the service. All of the staff we spoke with said that they felt the management team were responsive to their ideas and supported new initiatives. These included the current maintenance works that were being undertaken to improve the layout of the building including a 'caf' area for people using the service, and the proposed ideas for creating 'shop fronts' to help stimulate the minds of people living in Ashfields regarding shops and activities in the community.

The service had quality assurance systems in place to assess and monitor the quality of the service people received. We noted that there were action plans to address any identified shortfalls in service provision.

We saw that people were treated with respect and their dignity and independence was protected by staff who knew them and understood their needs well. People's care records reflected their individual needs and how they should be met. Regular reviews of care took place and any changes made known to staff.

The home was clean, tidy and free of unpleasant smells. Cleaning schedules were in place and up to date. Staff understood the need for infection control and there were effective systems in place to reduce the risk and spread of infection.

Staff told us they felt well supported and we saw that regular supervision and annual appraisals took place in order to identify training and other needs. Staff were trained to meet the specific needs of the people living at this home.

Records were well maintained, legible and easily accessible to staff. Personal records were stored securely and accessible only to relevant staff. They contained the information staff needed to care for people effectively.