Archived: Ashbourne Lodge

' Regulation 10, (Outcome 16): Assessing and monitoring the quality of service provision The service was not protecting people against the risks of unsafe care and treatment by not effectively assessing and monitoring the quality of service provided.

' Regulation 12, (Outcome 8): Cleanliness and infection control, as the service was failing to ensure people were protected from the identifiable risks of acquiring a health care associated infection.

' Regulation 22, (Outcome 13): Staffing The service was not taking appropriate steps to ensure that there were sufficient numbers of suitably qualified staff on duty at all times to meet people's needs.

During this inspection we spoke with the eight people who used the service and five relatives. We also spoke with the acting manager, two senior care staff, four care staff, the cook and housekeeper.

We also undertook general observations of practices within the home and we also reviewed relevant records. We looked at nine people's care records, recruitment records and the staff training records, as well as records relating to the management of the service. We looked around the service and went into some people's bedrooms, treatment rooms, all of the bathrooms and the communal areas.

We found that the provider had ensured improvements were made in these areas and these had led to the home meeting the above regulations.

During the inspection we found that the provider had commenced a range of processes designed to monitor and assess the ongoing performance of the home, such as audits. We found that this review had led to actions plans being developed. We saw that the processes that had been introduced would be effective in sustaining ongoing compliance with the regulations.

The manager and provider had reviewed and updated all of the records maintained at the home such as care records, audits, policies and training information. We found that where records such as care files had been reviewed these provided accurate information and were very informative.

We found that the building was very clean and well-maintained. Action had been taken to make sure the laundry was fit for purpose and did not present a fire risk.

People and the staff we spoke with told us that there were now enough staff on duty to meet people's needs. They found the staff worked very hard and were always busy supporting people. We found that the provider had increased staffing levels to ensure there were sufficient staff. Two senior care staff and six care staff were on duty during the day and two senior care staff and four staff on duty overnight. We found information about people's needs had been used to determine that this number of staff could meet people's needs. We noted that the provider's calculation would allow for additional staff to be on duty at peak times and the manager undertook to provide additional staff during peak times.

We carried out this out of hours inspection in order to review the improvements that the provider had told us had been made within the home and to allow us to investigate further the concerns that we had received. The inspection was unannounced and was completed by two adult social care inspectors. We have used our findings from the inspection visit to answer three of our five key questions, Is the service safe? Is the service effective? and is the service well led?

Is the service safe?

We found that people who used the service were not cared for in a clean, hygienic environment.

We found that the home had failed to appropriately assess the dependency needs of people who used the service in line with their own assessment tool. Changes to people's behaviours and findings from reassessment reviews had not been incorporated into the matrix for determining staffing levels. The home had failed to respond to concerns raised by staff in respect of their concerns about staffing levels within the home, specifically in relation to the night shift where planned lone working took place on two of the three units. During our visit we observed call bells ringing for prolonged periods of time before staff were able to respond. This meant that there were not enough qualified, skilled and experienced staff to meet people's needs.

Is the service effective?

We saw that the provider had taken reasonable steps to ensure that staff were supported within the workplace. Since our inspection in June 2014 all staff had received an appraisal and significant efforts had been made to ensure that all staff received regular supervision and development.

We found that action had been taken to address shortfalls in respect of mandatory training requirements. Where attendance for mandatory training was not at 100% we saw that there was an on going schedule of training programmes / courses in place to ensure that all staff will have completed mandatory training by April 2015.

Despite staff informing us of regular incidents of physical aggression from some people who used the service. we did not see any evidence that staff had received appropriate training to ensure their own safety, or the safety of others when incidents of this nature arose.

Is the service well led?

We saw that improvements had been made to ensure that records relating to people's care and the management of the regulated activity were accurate and fit for purpose. Records had been subject to review and audit since our inspection in June 2014. We saw that there was a mechanism in place to actively monitor evaluation and review of these records and that where necessary action was taken to address issues.

We found that personal records relating to people who used the service were not always stored securely. For example we saw that one office door was propped open and we were able to readily access personal records pertaining to people's health and care needs without challenge.

What people and staff told us:

One person we spoke with advised that they felt the staffing levels within the home were too low on late shifts. They told us of instances where they had heard call bells ringing for prolonged periods of time before staff were able to respond.

A visiting relative we spoke with raised concerns with us about the standard of cleanliness within the home. They told us of specific instances where used continence aids had remained in the bin within their relatives en suite for three days and was only removed when they raised their concerns with staff.

Staff we spoke with told us that they felt that staffing levels within the home did not enable them to meet the needs of people who used the service. They expressed concerns to us about the level of dependency that some people had, including moving and handling requirements and incidents of physical aggression from people who used the service. They told us that they felt vulnerable at times and that despite raising concerns with management no action had been taken to investigate or address their concerns.

Below is a summary of what we found. The summary is based on our observations during the inspection, looking at care records and speaking with the deputy manager, staff and observing people who lived at the service.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

We found that staffing levels at the time of our visit were acceptable to meet the needs of the people living at the service. We discussed with care staff that on some recent occasions, staffing levels on the Oak unit had fallen to one care staff which was below the two members of care staff that were scheduled to work during the evening. A senior carer showed us the rota and explained that some staff had taken short notice leave and sick leave and that the service had made attempts to source cover from their own staff and from agencies. The following day we spoke with the manager who explained the service was currently recruiting for more staff to join the bank of staff available to the service.

We observed care being given to people with dementia and staff were kind and supportive towards people. Staff members told us: 'I feel staffing is ok on an evening' and 'If it's fully staffed we can manage'.

The service had a registered manager in post, however they had been absent from work since December 2013. An interim manager had been providing support to the home over three days per week for the last four weeks. This interim support will remain in place until the registered manager returns to work. Prior to this time, the home's two deputy managers had been responsible for running the home.

During their four weeks in post, the interim manager had been making positive changes to the home. They displayed strong leadership and along with the two deputy managers they were working to create a positive environment for people and staff.

Records showed that CQC had been notified, as required by law, of all the incidents in the home that could affect the health safety and welfare of people.

During the inspection, the team worked together to answer five key questions which are outlined below.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

People told us they felt safe and secure living at the home. Relatives told us that they felt happy when they went home.

The home was not clean and well maintained. They were gaps in relation to record keeping for cleanliness. There were no procedures in place to ensure people's laundry was maintained during staff absence. People and their relatives expressed concerns about cleanliness and laundry. The provider could not demonstrate that people were protected from the risks of unsafe or inappropriate care because poor infection prevention and control measures were in place. A compliance action has been set in relation to this and the provider must tell us how they plan to improve. We have passed on our concerns to the local environmental health team.

We found gaps in the recording of information in people's records, in audits and in cleaning schedules. We found some records were unavailable during inspection. Records did not contain all the information required by the Health and Social Care Act. We also found that records in all three care offices were not stored securely. This meant the provider could not demonstrate that people were protected from the risks of unsafe or inappropriate care because records were incomplete. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications had needed to be submitted, proper policies and procedures were in place. Relevant staff had not been trained to understand where an application should be made, and how to submit one.

Is the service effective?

People had care plans in place which detailed their care needs. People spoke positively about the care which they received from staff. However people and their relatives told us they had not been involved in planning their care.

People had the assessments in place which they needed, however these were not always up to date.

People had access to a range of health care professionals, some of which visited the home. People told us staff escorted them to healthcare appointments if needed.

Staff training, appraisals and supervision were not up to date. This meant the provider could not demonstrate that staff were supported to provide appropriate care. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

Is the service caring?

Staff provided timely care and support to people. Staff showed patience and gave encouragement when supporting people.

Staff were knowledgeable about the people who they cared for. We could see that individual wishes for care and support were taken into account and respected.

Is the service responsive?

We could see that staff responded quickly when people's needs changed. However records were not always clear about the action which had been taken.

We found a lack of therapeutic activities in place at the home. We were told that no activities co-ordinator was currently in post. People and their relatives expressed concerns about the lack of activities.

Not all people and their relatives were involved in planning and reviewing their care.

Is the service well-led?

The service worked well with other agencies and services to make sure people received their care in a joined up way.

Staff were clear about their roles and responsibilities.

The home had a system to assure the quality of service they provided. However audits were not always kept up to date and no meetings for people and their relatives had taken place. The interim manager had plans in place to address this.

Information from the analysis of accidents and incidents had been used to identify changes and improvements to minimise the risk of them happening again.

We found that people relatives and staff had completed a survey, however no formal analysis of the results had taken place.

What people said

People who were able to express their views told us they were satisfied with the care and support they received. We heard comments such as, 'The quality of care is good,' 'I am well looked after' and 'We get looked after very well and all of the carers are very nice. I do think that they have too much to do.'

People and relatives spoke positively about the care and support they received, however some people told us they would like the opportunity to have more frequent baths and showers.

People and relatives expressed concerns about the quality of food and the procedures in place for dealing with laundry.

We found that before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. People experienced care, treatment and support that met their needs and protected their rights.

People who used the service, staff and visitors were protected against the risks of unsafe or unsuitable premises.

We found that there were effective recruitment and selection processes in place.

We found that Ashbourne Lodge had improved the records for those people receiving respite care. This meant that people were now protected from the risks of unsafe or inappropriate care and treatment because accurate records were maintained.

We spoke with four people who lived at Ashbourne Lodge and two visiting friends of residents. Everyone was complimentary of the quality of care they received. One person said, "I think it's a good home. I've visited a few homes where friends stay and I think this is one of the better ones.'

There was a calm friendly atmosphere around the home and people were seen to respond positively to the staff throughout. The environment was clean, bright, modern and free from unpleasant odours.

Everybody we spoke with told us they felt safe at Ashbourne Lodge and with the care staff employed by the service. People said the staff knew them well and how best to help and support them in their everyday life. One person said "We are very well cared for; they're good girls who work here. They make it as much like home as they can'.

There were arrangements in place to gain additional feedback about services from user satisfaction surveys, relatives and staff questionnaires.

The information and documents within some people's care plans contained insufficient detail to ensure that people were protected against the risks of unsafe or inappropriate care and treatment.