Ashleigh Manor Residential Care Home

Ashleigh Manor Residential Care Home is a residential care home providing accommodation and personal

care to up to 65 people. The service primarily provides support to people living with dementia. At the time of

our inspection there were 45 people using the service.

The service is divided into two adjoining units. There are a variety of communal areas and a garden people can use.

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

Training had improved since the last inspection. There was a plan in place to help ensure staff training was up to date and this was supported by a programme of competency assessments.

People’s needs and preferences were assessed on an ongoing basis. This helped staff tailor support to their needs. Staff were proactive in delivering dementia care in line with best practice.

People gave positive feedback about the meals. Information was displayed about the food available and people’s individual dietary needs were catered for.

People were supported to maintain their health. Support and advice from external professionals were sought when necessary.

Assessments of people’s capacity had been completed and decisions had been made in people’s best interests, when necessary. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People and their relatives were consulted about what to include in people’s care plans. Care plans were regularly reviewed to help ensure they reflected people’s current needs. Different communication formats and tools were available to meet people’s needs.

Activities provision at the service had improved. People had a variety of options available to them and were able to suggest things they would like to do. Staff were working towards enabling people to become more involved in their local community. Staff did not monitor whether people had regular access to activities, interests or pastimes that were particularly important to their mental health or wellbeing. We made a recommendation about this.

There was a range of checks, audits and meetings used to identify any areas for improvement. Action was taken promptly in response to any concerns or ideas.

The atmosphere in the service had improved following recent changes. People had more to do and this had improved staff morale.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 26 April 2022) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

At our last inspection we recommended that the provider sought advice on how to effectively record people's fluid intake. At this inspection we found improvements had been made.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection. We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions; Effective, Responsive and Well-Led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Ashleigh Manor Residential Care Home on our website at www.cqc.org.uk

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 made a recommendation about monitoring people’s access to activities, pastimes and interests that were important to their mental health or wellbeing.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Ashleigh Manor Residential Care Home is a residential care home providing accommodation and personal care to up to 65 people. The service primarily provides support to people living with dementia. At the time of our inspection there were 51 people using the service.

The service is divided into two adjoining units. One for people with more complex needs called The Manor and another for people with lower care needs called The Lodge. There were a variety of communal areas and a garden people could use.

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

Staff’s training was not all up to date. Staff had not always received training in key areas relating to people’s care needs, such as catheter care, falls or skin care, or safeguarding.

People did not have enough to do. There were not enough opportunities available in the service for people to remain stimulated.

The provider had identified some areas of improvement but had failed to take enough action to make the necessary improvements. Checks and audits of the service were completed but these had not identified some of the areas for improvement found during the inspection.

People and relatives told us they thought the service was short staffed. They told us staff were good but rushed. The registered manager told us they monitored people’s needs to help ensure there were enough staff available, but staff also told us they felt rushed.

The provider had taken a variety of actions to improve people’s experience of mealtimes. People were able to influence menus and received tailored support to help ensure they ate and drank enough. Food and fluid charts were used when necessary and were competed well but did not contain information to guide staff about how much each person needed to drink to remain healthy.

Staff were recruited safely and understood how to reduce risks to people.

People’s medicines were well managed, and they received them safely as prescribed.

People’s care plans detailed their needs and preferences. Staff understood these and were able to spend time getting to know people. People were supported to remain healthy and external professionals were contacted for support when needed.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People and relatives told us they were happy and confident raising concerns with the registered manager or provider.

The provider regularly reviewed the environment to help ensure it met people’s needs and preferences.

People and relatives had good relationships with staff and were regularly consulted about improvements to the service.

Rating at last inspection and update

The last rating for this service was requires improvement (published 24 August 2021) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations. This service has been rated below good for the last seven consecutive inspections.

Why we inspected

We received concerns in relation to the safety and quality of the care people received. As a result, we undertook a focused inspection to review the key questions of safe, effective, responsive and well-led only.

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.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

We have found evidence that the provider needs to make improvements. Please see the effective, responsive and well led key question sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Ashleigh Manor Residential Care Home on our website at www.cqc.org.uk.

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 training, person-centred care and governance at this inspection.

We have made recommendations about staff safeguarding training and staffing levels and deployment and how staff record how much people drink.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

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

People and relatives’ comments about meals, varied. The provider explained how they recognised improvements were required and were making steps to enhance the mealtime experience for people.

Despite people living at the service telling us they knew who to complain to, we found that some people did not always want to speak up, for a fear of repercussion, with one person telling us “I don’t like complaining”.

People now had care plans in place that were reflective of their needs. People’s relatives told us they felt there was enough socially for their loved ones to do, which they felt took account of their abilities as well as their interest to engage. However, we found the culture of the service was not always necessarily aimed at encouraging, engaging and helping to facilitate participation for people to remain socially stimulated.

The service worked with external professionals to ensure people’s health and care needs were met consistently and effectively.

People lived in an environment that had been designed to meet their needs. The provider was in the process of re-designing the garden to enable people to have a brighter space to enjoy; which included creating additional plant and vegetable patches.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

You can see what action we have asked the provider to take at the end of this full report.

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

Rating at last inspection (and update)

The last rating for the service was Good published on (30/09/2020).

Why we inspected

We carried out a focused inspection of this service on 11/09/2021. Improvements were required in respect of the Effective and Responsive key questions.

We undertook this focused inspection to ensure improvements had been made. This report only covers our findings in relation to the Key Questions Effective, Responsive and Well-led which contain those requirements. We found a breach of regulations in relation to the governance of the service.

We also 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.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has deteriorated to requires improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Ashleigh Manor Residential Care Home on our website at www.cqc.org.uk.

Follow up

We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Ashleigh Manor Residential Care Home (hereafter referred to as Ashleigh Manor) is a residential care home providing personal and nursing care to 27 people aged 65 and over at the time of the inspection. The service is registered to support up to 65 people.

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

People told us they felt safe living in the service. Relatives gave us good feedback about the safety and quality of care and improved communication. Safeguarding concerns were recorded, reported and investigated.

The service was clean, tidy and odour free. We saw staff wearing masks, gloves and aprons in line with government guidance. There were robust infection control processes being observed and thorough health and safety checks on the safety of equipment and the environment.

There were processes in place so lessons could be learned when incidents or accidents happened. This learning was then shared amongst all staff. There were enough staff to keep people safe and robust recruitment processes were followed.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Quality assurance systems had been improved and there were multiple checks by different staff on safety and quality aspects of care. Staff had clear responsibilities and information was handed over between staff regarding risks.

Staff felt supported and we saw a registered manager who was growing in confidence and leading an improving service. The culture was more open, and we saw evidence people were supported to achieve positive health outcomes.

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

Rating at last inspection (and update)

The last rating for this service was requires improvement (published 6 November 2019) and there were two breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve and sent us monthly reports that were required by the conditions of their registration. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating. 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 coronavirus and other infection outbreaks effectively.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Ashleigh Manor Residential Care Home on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Ashleigh Manor Residential Care Home (hereafter referred to as Ashleigh Manor) is a residential care home registered to provide personal and nursing care for up to 65 older people. However, the local authority had stipulated admissions to the service were capped at a total of 28 after the last inspection where serious concerns were raised. There were 27 people living in the service at the time of this inspection.

Since our last inspection we found improvement had been made in every domain we inspected. Care staff and the registered manager and provider had worked hard in raising the standard of care.

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

Risk information was not always handed over between staff and we observed one instance where the advice of a healthcare professional was not followed, and a person was placed at risk of choking. The person was not harmed, and the service acted swiftly.

Records around fluid intake for people at risk of dehydration were not always totalled and there was no guidance in place to tell staff what a safe level of fluid intake was for each person. By the end of the third day of inspection this had been remedied and a new system of assessing nutrition and hydration needs was introduced and communicated to all staff.

Care plans were not always up to date, and some life histories were not rich in detail regarding people’s lives before they came to the service and what their preferences were. Despite this, people told us staff knew what their preferences were for how they liked to be supported with personal care.

We saw improvements in the running of the service and audits were more robust. However, they failed to pick up the issues we identified on inspection and needed further embedding. We were concerned that there was going to be another change in management for the service, particularly as the leadership had a history of being unstable and lacking consistency.

Staff felt supported and had supervisions with a team leader or the registered manager. Staff morale was improving, and people and relatives said staff were caring and kind.

Healthcare professionals told us communication had improved between staff and visiting professionals and the culture of the service was more open and positive.

People told us they enjoyed the food and they were offered options and a variety of drinks were offered throughout the day.

People and relatives knew how to raise any concerns and were listened to. One relative told us the end of life care was thoughtful and considerate.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

We saw lots of improvement since we last inspected six months ago. However, we did identify two repeat breaches of regulation regarding safe care and treatment and good governance. We made one recommendation around more in-depth training for staff in supporting people living with dementia.

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

Rating at last inspection (and update)

The last rating for this service was inadequate (published 5 March 2019). The provider completed an action plan after the last inspection to show what they would do and by when to improve. We followed our enforcement processes after the last inspection and proposed to cancel registration. The provider submitted representations against this proposal and they were not upheld, we re-inspected and found some improvements in some areas. The outcome of this process that was started after the last inspection and continued after this inspection is that conditions have been added to the registration of the provider. We will continue to closely monitor this service.

At this inspection enough improvement had not been made/sustained, and the provider was still in breach of regulations. The rating of the service for this inspection is requires improvement, the service has been rated requires improvement or inadequate for the previous four inspections.

This service has been in Special Measures since 4 March 2019. During this inspection the provider demonstrated that some improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This was a planned inspection based on the previous rating and to follow up on action we told the provider to take at the last inspection.

Enforcement

We have identified breaches in relation to governance, risk management and people’s safety. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

People’s experience of using this service:

•The quality of people’s care continued to raise serious concerns.

•People dependent on staff to pre-empt and meet their needs were being failed by the service.

•People were not receiving care that was fully safe, effective, caring, responsive to their needs and well-led.

•The service is now judged to be inadequate in keeping people safe, providing effective care as well as continuing to be inadequately well-led.

Rating at last inspection: The rating at the last inspection was Requires improvement overall. The report was published on the 8 August 2018. This service had been rated repeat Requires improvement at the previous two inspections. They were last rated as Good in 2015.

Why we inspected: We inspected in line with our inspection methodology. This was within six months of publication as the service had been judged to be Inadequate in well-led at the last inspection. Prior to this inspection, the service was also placed into whole home safeguarding by the local authority due to a number of concerns in respect of people’s care. CQC have been liaising closely with the local safeguarding adults team. The areas of concern were used to inform our planning for this inspection.

Enforcement: Following our last inspection we added positive conditions to the provider’s registration. This required them to report to us each month to ensure we could monitor their progress. On this inspection, we found some conditions were met and others were not. Whilst some elements of the conditions had been met this had not led to sustained improvements and in many areas, we identified deterioration in people’s care.

In respect of this inspection, full information about CQC’s regulatory response to the more serious concerns found in inspections and appeals is added to reports after any representations and appeals have been concluded.

Follow up: The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Our information raised concerns about the number of falls resulting in injury, medicine errors, how people’s continence care was being managed and moving and handling practices.

We were told there was not enough staff or the right equipment to meet people’s needs. Also, people’s medicines were not being fully signed for, people were not having their prescribed creams put on their skin and people’s continence needs were not being met. Staff were also not reading care plans so were unaware of people’s needs and preferences.

In addition, there were concerns about staff were not speaking to people, staff not wearing gloves and aprons as they should and staff were not passing concerns on to management and complaints were not being dealt with appropriately.

When we completed our previous inspection on 27 and 28 September 2017 we found concerns relating to staffing levels; gaps in medicine records; people’s care plans not fully reflecting their care; activities not being personalised and the provider was not ensuring the quality of the service. This meant we rated the key questions of Safe, Responsive and Well-led as Requires improvement. Effective and Caring key questions were rated as Good.

We requested the provider to tell us in an action plan how they were going to put right the concerns in respect of breaches of Regulations for staffing the service safely; assessing, monitoring and improving the quality of the service and in ensuring people’s records were complete and accurate.

Ashleigh Manor is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Ashleigh Manor can accommodate 65 people in two separate parts of the premises. These are known as ‘The Manor’ and ‘The Lodge’. Historically, people in The Manor are living with dementia or complex needs and people of reduced complexity lived in The Lodge. However, on this inspection we found people had complex needs in both parts. When we inspected, there were 51 people living at the service. The Manor had 25 people living there and 26 in The Lodge.

A registered manager was not currently in place in respect of this service. However, the current manager was in the process of registering with us. 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. They were supported in running the service by a care manager, two administrators and one of the registered partners/provider. One of the provider’s daughters acted on behalf of the registered provider during the inspection with the main partner/provider attending the second day of the inspection.

On this inspection, we reviewed the concerns we had received and checked to see if the provider was compliant following the last inspection. We found some improvements had been made in some areas but we also found continued concerns and some new concerns that are summarised below.

Staff described the lack of staff and equipment as the two main issues impacting on people.

Robust quality assurance processes were not operating. Audits of parts of the service were not in place or being reflected on to ensure all areas of the service were operating safely, effectively, caringly or responsively.

Staff told us they felt unsafe speaking out about how they were feeling as “it got round” if you spoke out. We advised the provider of this, who met with the staff to seek their concerns and issues.

The service was not staffed safely to meet people’s needs. The service was also not staffed in line with the stated provider’s minimum staffing levels. Also, staff from the Lodge were being repeatedly moved to fill gaps in staffing the Manor. As a result people’s basic care needs were not being met; people were not always having their hydration needs met, people did not always have choice and the quality of their care was compromised. On the second day of the inspection, the emergency call bell was sounding repeatedly for long periods as staff were unable to respond in the expected time to meet people’s requests. Only care staff were expected to respond to these bells; team leaders and management were not. This meant an air of complacency had developed in respect of the risk to people.

The service also did not have the required equipment to meet people’s needs in a timely way. There were two hoists and one stand aid, without the required sole use sling, which meant people had to wait for equipment to become available. The only wet rooms that were accessible by a wheelchair and two staff were found in the Manor. People from the Lodge were less likely to have their chosen shower routine at a time they wished and when this did take place, people were rushed due to availability of enough staff. We found that staff were not always using slide sheets for people who required help with moving and handling. These are used to move people in bed while reducing the friction on the skin.

Staff were observed being kind and compassionate to people throughout the inspection, but their ability to have quality time with people was being compromised by all the tasks they needed to complete.

Demands on staff time meant that staff were not reading people’s care plans and risk assessments. Care staff relied on the team leader to tell them informally and verbal information from other staff. Although care plan records had improved since the last inspection, essential details were still missing from these and the risk assessments which meant the team leaders could not be sure they were using up to date information about people’s current needs. Care records were not fully completed which meant people’s changing needs could be missed. Monitoring of people’s eating, fluid intake and out puts (such as urine and bowels) were inconsistently being recorded. This meant people were vulnerable to unsafe and inaccurate care.

People’s oral medicines were recorded and the systems around this had improved since the last inspection. However, those in relation to people’s prescribed creams had not. Staff were not recording when they had been used, opened, needed disposing or making sure new creams were available. Where body maps were in place to help staff know what topical medicine to use they did not include when and not all creams were represented.

Staff were not being trained to effectively carry out their role. Staff training in many key areas had lapsed or had not been completed at all. Staff were relying on being told by other staff what was the right way to do things. Supervisions and staff competency assessments (except around medicines) had recently been reintroduced. People’s capacity to consent to their care was considered, however staff had not always had the training to understand how this applied to their role. This was again placing people at risk of unsafe care.

People’s experience of care was also affected by the level of stimulation and activity available, which varied in The Manor and The Lodge. People living in the Manor tended to experience a higher level of stimulation than those living in the Lodge.

However, the chef interacted with people and, along with the kitchen staff generally, was highly regarded by people, staff and relatives. People were very positive of the food and grateful for the lengths the kitchen staff went to ensure they had what they liked to eat.

Some areas of fire safety and maintenance of the building required improvement. The fire service had visited and given verbal advice. We were told new systems of overseeing maintenance and fire safety had been introduced recently followed by a gap in ensuring these were monitored.

We found little evidence of compliance with the Accessible Information Standards and how the service was ensuring people’s Equality, Diversity and Human Rights Needs were being incorporated into their care. The Accessible Information Standard applies to people using the service (and where appropriate carers and parents) who have information or communication needs relating to a disability, impairment or sensory loss. However, people could have access to professional advocates to speak on their behalf if needed. A signer was provided for one person who was deaf and used sign language when having health meetings; but staff did not following advice from to maintain a good face to face position so the person could lip read.

People were protected from infection cross contamination due to clear processes and practices being in place. However, not all staff had received training in infection control. People, and their families, were positive about being able to approach staff at any time to talk about their care. People’s complaints were looked at in detail and action taken to put things right.

People’s health needs were met and they could see a range of health and social care professionals as needed. The visiting nurse we spoke with was happy the service would call them if needed.

We found breaches of the regulations. We are considering o

We carried out this unannounced inspection of Ashleigh Manor Residential Care Home on 27 and 28 September 2017. At this comprehensive inspection we checked to see if the service had made the required improvements identified at the inspection in November 2016.

There was not a registered manager in post as the previous registered manager had left working for the service in August 2017. Another manager was appointed soon after who was responsible for the day-to-day running of the service. This manager told us they intended to apply to become the new 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 and associated Regulations about how the service is run.

In November 2016 we found aspects of the service provided to people that were not safe. People’s medicines were not managed safely. Risks were not being assessed for people in relation to the risk of choking, the risk of smoking and how to manage risks associated with specific health conditions. Staff were carrying out some care and treatment without the qualifications and competence to do so. Equipment used for staff to carry out health checks and first aid were not properly maintained or used correctly. There was a lack of robust procedures in relation to the prevention and control of the spread of infection.

At this inspection we found improvements had been made. Risk assessments had been updated and individual assessments were in place which identified any risks relevant to the person and gave instructions for staff to help manage the risks. Equipment used for staff to carry out health checks and first aid had been serviced and there was a system in place for regular servicing. Team leaders had been trained to carry out some routine health checks and the service had ceased carrying out some other checks. Revised infection control procedures had been implemented and a head of infection control and housekeeping had been appointed. The service was visibly clean throughout and there were suitable levels of PPE (Personal Protective Equipment).

A review of medicines procedures and an update of staff training meant people were receiving their medicines in a mostly safe way. There were gaps in records for when staff applied creams. Some people were prescribed to have medicines administered by an external health professional every three months. There were no records made to show when the next administrations were due and we found that one person was overdue their medicine.

In November 2016 while we found there were sufficient staff on duty, based on the provider’s dependency assessment, staff were not always deployed effectively. There were gaps in the information communicated to staff when they started a shift and staff were not always clear about their responsibilities. This meant staff were not being used effectively and flexibly to meet people’s needs. At this inspection we found improvements had been made to the structure of how staff were deployed. Roles and responsibilities had been defined and communicated to staff. Handovers had improved and staff told us they felt more confident about carrying out their roles. However, the number of staff on duty regularly fell below the level assessed by the provider as being needed to meet people’s needs. This impacted on the time staff had available to talk with people, other than when they were completing tasks for them. We found the provider had not sufficiently monitored the impact that lower staffing levels had had on the quality of the service provided for people.

At the last inspection we found people’s mental capacity was not being assessed in line with the Mental Capacity Act 2005. Decisions were being made, in people’s best interests, without ensuring there was a mental capacity assessment in place. At this inspection we found the service was working within the Mental Capacity Act (2005) as mental capacity assessments had been completed for each person. These assessments covered a range of day-to-day decisions as well as more significant decisions that might need to be made in the person’s best interest.

At the previous inspection we found there were gaps in daily records, records of people’s health appointments and food and fluid monitoring charts. There was a lack of care plans for people who were at the service for a short stay. People did not have their end of life wishes and needs assessed. In addition because staff were not clear about their roles and responsibilities communication between staff was inconsistent. Information and advice from healthcare professionals, about how to care for people, was not always being acted on. At this inspection we found improvements had been made. Daily records, records of healthcare professional visits and food and fluid monitoring charts had been consistently completed. The staffing and management structure had been reviewed and provided staff with a better understanding of their roles and who to report to. There was evidence of healthcare professional involvement. Appropriate referrals had been made and staff had acted on guidance and instructions given by external professionals.

While overall the recording of the care provided for people had improved we found some people’s care plans lacked important detail. Where people could display behaviour that might challenge others, their care plan did not give guidance for staff about how to respond to that behaviour or what might trigger it. It was clear from speaking with staff that they understood people’s behaviour and possible triggers. However, there was a risk that, without a record of how staff should respond new staff may not be able to meet people’s needs.

At the time of the last inspection we had not been notified of all incidents as required by people registered with us. Services are required to notify CQC of various events and incidents to allow us to monitor the service. At this inspection the manager had ensured that notifications of such events had been submitted to CQC appropriately.

Before this inspection we received concerns about people being left for long periods in continence pads, incorrect manual handling practices, low staffing levels and the overuse of medicines to calm people’s behaviour. Apart from our concerns about staffing levels, detailed above, we did not find any evidence to substantiate the issues raised.

People and their relatives told us they thought the service was safe. Comments included, “I feel safe here”, “It’s nice here”, “It’s alright here” and “No complaints at all.” The atmosphere at the service was pleasant and relaxed. We saw staff interacted with people in a caring and compassionate manner. People and their relatives told us the staff were kind. Comments included, “Staff are brilliant. I have always found they do their upmost to see people are happy”, “They look after her well”, “Staff are good. They are very fond of him” and “Staff couldn’t have done more when he first moved in.”

Staff had been safely recruited, and had undergone checks to help ensure they were suitable to work with people who were vulnerable. Staff knew how to recognise and report any signs of suspected abuse or mistreatment.

People were supported by staff who had undergone training to help ensure they could meet their needs effectively. Specialist dementia training had been arranged and advice sort about making adaptions to the environment to help people with dementia orientate around the premises. We have made a recommendation about appropriate signage for people with dementia.

Staff supported people to maintain a balanced diet in line with their dietary needs and preferences. People told us they enjoyed their meals. Comments were, “Breakfast was nice”, “I am happy with the food” and “Mum has to have pureed food, but they make it look appetising.”

Staff ensured people kept in touch with family and friends. Relatives told us they were always made welcome and were able to visit at any time.

There was an activities programme that included group activities, facilitated by the activities coordinator, external entertainers and regular trips out in the service’s mini bus. However, we saw little evidence of personalised activities taking place, especially for people living with dementia. We have made a recommendation about this.

People and their families were given information about how to complain. People and relatives all described the management of the home as open and approachable. There were regular meetings for people and their families, which meant they could share their views about the running of the service. Relatives commented, “They don’t gloss over anything, very open to feedback and they listen” and “The recent meeting was very good. They were honest about the things that need to be improved and I am confident the improvements will be made.”

Staff were positive about the new management of the service and recent changes to the staffing structure meant staff understood their roles and responsibilities. Comments from staff included, “The new manager is doing really well”, “It seems more organised” and “The atmosphere has changed and there are new systems in place” and “The manager’s door is always open, you can talk to them at any time.”

There were qu

The inspection took place on the 1, 2 and 3 November 2016 and was unannounced. We completed a comprehensive inspection on the 30 June 2015 and rated the service as Good. Prior to this inspection we were contacted by the local authority to be advised there were a number of safeguarding concerns being investigated by social workers. These covered a wide range of issues including how the service was addressing risks to people in respect of falls, malnutrition and their skin. Concerns were also raised regarding staffing, training, the cleanliness of the service and how people’s individual needs were being met. CQC had also received information about errors in medicine administration since the last inspection. This included giving medicines to the wrong person. We reviewed the concerns raised during the inspection and found a number of concerns which reflected the same issues we had been told about prior to our visit.

Ashleigh Manor Care Centre (known locally as “Ashleigh Manor”) is registered to provide care to up to 65 older people who may be living with dementia and/or have a physical disability. There were 57 people living at the service when we visited. Ashleigh Manor had two sides with separate entrances to the one service. There was “The Manor” where people with more complex needs lived. Then there was “The Lodge” where people who had lower needs resided.

A registered manager is registered with the CQC but is no longer in post. 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. A new manager had been in post since 19 September 2016. They were in the process of registering with us.

Throughout the inspection we identified that systems were not always in place to ensure the service was safe, effective, caring, responsive and well-led. This affected several aspects of people’s lives while living at the service. For example, staff were making decisions about people’s care and treatment without communicating this to senior management. Staff were also not always recording this information so it was available for other staff to meet people’s needs in a consistent way. Health professionals told us messages were not always passed on or they could not speak with the staff member who held the information they needed. This impacted on their ability to assess people’s needs fully.

People’s care and treatment was not always planned to keep them safe or meet their needs in a personalised way. From admission to living short or long term at the service, there were gaps in people’s records. Information about people from the referring agency or discussions with people were not always being acted on. Risk assessments were not always completed which reflected people’s needs. For example, the risk of choking or from specific health needs, such as diabetes, was not being assessed. Information which was essential to staff meeting their needs and keep them safe was not being collated. People were not having their end of life wishes and needs assessed.

Staff recording of aspects of people’s care was variable and incomplete. For example, recording of how much people were eating and drinking when there were concerns had gaps in it. Whether staff were applying prescribed creams was not being recorded. Daily records of people’s days and significant events were inconsistent or had not been recorded at all. This meant it was unclear whether people were having their needs met.

People were not being assessed in line with the Mental Capacity Act 2005. Some people had generalised assessments in place when it was felt they lacked the capacity to consent to their care. Decisions were being made about people’s care without ensuring there was a mental capacity assessment in place and that decisions were being made in their best interests.

People’s medicines were not always managed in a safe way. Some staff needed to have their training updated and competency to complete this role checked. Staff were completing tasks they had not been trained to do. Training in general, along with systems to ensure staff had regular updates and training to meet people’s specific needs, had been completely re planned. The aim was to put in place the essential training first and for all areas to be covered by the end of March 2017.

Audits to measure the quality of the service were not always taking place. For example, there was no audit of infection control. An audit of medicines had been introduced recently with the aim that there were daily, weekly and monthly checks to improve practice. A review of care plans had resulted in a new system being introduced to ensure they were personalised. We have told the local Environmental Health Officer of concerns around some aspects of infection control.

CQC had not always been told of incidents which registered people are required to tell us about. We were concerned we had not been told about incidences when a person had been injured and safeguarding concerns had not been shared.

During the inspection there were enough staff to meet people’s needs. Systems were not being used to ensure there were enough staff that was flexible to meet people’s needs. For example, an assessment of people’s dependency on staff was not being completed. We have recommended the provider puts in place systems to ensure staffing reflects people’s current needs and has the flexibility to deal with changes people may experience from time to time. Staff were recruited safely. Staff knew how to identify abuse and would act if they had a concern. They felt action would be taken by the manager to address any concerns.

People gave us a mixed response as to whether they felt staff treated them in a respectful manner at all times. Some staff were spoken of highly while other staff were described negatively. People said staff always respected their dignity when they were receiving personal care. Staff spoke passionately about people they were looking after and demonstrated they knew people well. Staff wanted people to be looked after to the highest level and felt the new manager would bring this about.

We spoke with the new manager on several occasions throughout and immediately following the inspection. They provided a copy of their action plan which had been submitted to the local authority and stated how they were going to meet the immediate needs. They had the experience of being a manager of care homes before and described the systems they were bringing in. For example, new care plans, new communication books and working with team leaders to ensure they were clear of their role. The manager also spoke of the high standard of care they expected all staff to deliver and people should receive. A lot had been achieved in a short time frame and they took on board the feedback from the inspection and amended the action plan to include this.

People were happy with the food and were provided with food as they liked it. Kitchen staff were knowledgeable about people’s needs and looked for ways to encourage people to eat when they were not feeling like it. The main kitchen and stores were kept to a high standard of cleanliness. Family and visitors told us they were happy with the staff and how the service was meeting their loved ones needs. They said they were always welcomed.

Systems were in place to ensure the building and equipment were safe. Other equipment was to be added to these when we identified they required monitoring. For example, machines to test people’s blood sugar levels.

We found breaches of the regulations. You can read what we have told the provider to do at the back of the full report.

We saw people's privacy and dignity being respected at all times. We saw and heard staff speak to people in a way that demonstrated a good understanding by staff of people's choices and preferences.

We looked at care records for four people. We spoke to staff about the care given, looked at records relating to them, met with them and observed staff working with them.

We saw that people's care records described their needs and how those needs were met. This meant that people's care and welfare needs were being met.

We saw that medication was administered by suitably trained staff. People were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to administer and record medication.

We saw that Ashleigh Manor Residential Home held all records securely to protect people's confidentiality.

People living in Ashleigh Manor received care or treatment staff attempted to obtain consent when possible and the staff acted in accordance with their wishes.

We saw that people were left for long periods without any interaction.

Staff we spoke with were clear about the actions they would take should they have any concerns about people's care and welfare.

We looked at care records for six people living in Ashleigh Manor. We spoke with staff about the care given, looked at records relating to them, met with them and observed staff working with them.

We saw people's privacy and dignity being respected. We saw and heard staff speak to people in a way that demonstrated a good understanding by staff of people's choices and preferences.

Care plans did not always reflect people's health and social care needs. People were not always updated about their care needs. This meant that people's care and welfare needs may not have been met. We saw that people's mental capacity was assessed to determine whether they were able to make particular decisions about their lives.

People who lived in the home were not always informed about changes in the management of the home

We spoke with most of the staff working during our visit. Some of the staff had worked at the home for some time and one said, 'I love my job'.

We spoke to sixteen people who used the service, eleven staff members and one visiting relative. We also observed staff interaction with people as some were unable to communicate with us. We talked with the staff and the recently appointed registered manager.

We looked at the care records of four people who used services and this involved looking at the eating and drinking sections of the care plans, with a follow up look at weight charts, food and fluid charts and monitoring of all these aspects for people's wellbeing.

We saw and heard staff speak to people in a way that demonstrated a good understanding of people's choices and preferences. We spoke to staff about the meals provided, looked at records related to individual's eating and nutritional needs and met with individuals and observed staff working with them, particularly at a main meal time.

There were enough staff on duty to meet people's needs with additional staff available when required. Staff had received training to enable them to carry out their roles competently and ongoing training was available.

We looked around the home and found that it was clean and hygienic.

We examined the care files belonging to four people who lived in the home and found that they were in the process of being reviewed and updated as people's needs/wishes changed.

We found that people were offered choices and were consulted and involved in decisions about their care and support needs. People saw healthcare professionals on a regular basis or when they needed them. People were treated with respect by the staff who upheld people's rights to privacy and dignity. Comments from the people we spoke with included "they shower me with kindness", "if things are worrying you, they find time to listen" and "staff are polite and friendly all the time".

There were enough staff on duty to meet people's needs with additional staff available when required. Staff had received training to enable them to carry out their roles competently and ongoing training was available.

There were effective systems in place for safeguarding people from abuse and monitoring the quality of the service to ensure that people's views were listened to and action taken where required.

During our visit we spoke with five people who used the service, two relatives and the registered manager. We spent time observing people and how staff interacted and supported them.

A relative of a person using the service told us "people here are lovely". A person using the service told us that they "were surrounded by such good friends". They told us that they had "made the right choice in coming here".

We looked around the home, and saw nothing that could pose a danger to people living there.

We examined care files belonging to three people who lived in Ashleigh Manor Residential Home and found that risk assessments were in place. These included mobility assessments. Where accidents had happened, for example a fall, the records we saw had been updated to reflect the accident and further controls were implemented to reduce the risk.

You can see our judgement on the front page of this report.

At the time of our visit there were compliance actions open from a previous inspection. The provider had provided a plan to the commission to address these actions. The timescale for completing the actions had not yet past at the time of the visit. We saw the provider had been making progress with the actions.