Archived: Ashcroft - Bromley

At the last inspection on 27, 28 and 29 November and 05 December 2016 we found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 because staff had not always received appropriate training. Following that inspection the provider sent us an action plan showing how they planned to make improvements. We undertook a focused inspection on 18 May 2017, to check that they had followed their action plan with regard to staff training and found they complied with the regulations. However, although improvements have been made, we were unable to change the rating of this key question at that inspection. This was because there were other areas such as supervision and appraisals in the key question that were rated as requires improvement at the last comprehensive inspection that we did not look at during the focused inspection.

At this inspection, we found the provider trained staff to support people and meet their needs. People and their relatives told us that staff were knowledgeable about their roles and that they were satisfied with the way staff looked after them. The provider supported staff through bi-monthly supervision and yearly appraisal.

The service did not have a registered manager in post. The previous registered manager left the service in March 2016. However the provider appointed a new manager to run the home. The new manager’s application to the CQC to become the registered manager was being processed. 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.

Staff knew how to keep people safe. The service had clear procedures to support staff to recognise and respond to abuse. The manager and staff completed safeguarding training. Staff completed risk assessments for every person who used the service and they were up to date with detailed guidance for staff to reduce risks.

The service had an effective system to manage accidents and incidents, and to prevent them happening again. The service carried out comprehensive background checks of staff before they started working and there were enough staff to support to people.

Medicines were managed appropriately and people were receiving their medicines as prescribed. Staff received medicines management training and their competency was checked. All medicines were stored safely. The service had arrangements to deal with emergencies and staff were aware of the provider’s infection control procedures and they maintained the premises safely.

The manager and staff understood their roles and responsibilities under the Mental Capacity Act 2005 (MCA) Deprivation of Liberty Safeguards (DoLS). They had taken action to ensure the requirements were followed for the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). People consented to their care staff provided them.

Staff assessed people’s nutritional needs and supported them to maintain a balanced diet. Staff supported people to access the healthcare services they required, and monitored their healthcare appointments. The manager and staff liaised with external health and social care professionals to meet people’s needs.

People or their relatives, where appropriate, were involved in the assessment, planning and review of their care. Staff considered people’s choices, health and social care needs, and their general wellbeing.

Staff supported people in a way which was kind, caring, and respectful. Staff protected people’s privacy and dignity.

The provider recognised people’s need for stimulation and social interaction. People had end-of-life care plans in place to ensure their preferences at the end of their lives were met. Staff completed daily care records to show what support and care they provided to each person.

The service had a clear policy and procedure about managing complaints. People knew how to complain and told us they would do so if necessary.

The service sought the views of people who used the services, their relatives, and staff to improve the service. Staff felt supported by the manager. The provider had effective systems and processes to assess and monitor the quality of the care people received which helped drive service improvements. The service worked effectively with health and social care professionals, and commissioners.

After the comprehensive inspection, the provider sent us an action plan to say what they would do to ensure they met the fundamental standards. We undertook this unannounced focused inspection on 18 May 2017 to check that they had followed their action plan with regard to staff training and to confirm that they now complied with the regulations.

Ashcroft Nursing Home provides accommodation and nursing care for up to 22 people with residential and/or nursing needs, including end of life care. On the day of the inspection there were 20 people living at the home.

There was no registered manager in place. The home had been managed by the deputy manager since the previous registered manager de-registered in March 2016. The deputy manager told us they were in the process of applying to become the registered manager of 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 2008 and associated Regulations about how the service is run.

At this inspection we found improvements had been made to the arrangements for staff training and staff were provided with the training they needed. The training policy had been updated and the provider had a list of the mandatory and additional training expected of staff to ensure they could meet people’s needs safely. We found recent training, including moving and handling training had been provided by an external trainer. Nursing staff had received additional training in areas such as specialist feeding techniques to ensure they could meet the clinical needs of the people they cared for. Staff told us they thought their recent training had been effective and useful to them to help them to meet people’s needs. the home now met regulatory requirements in this respect.

However, although improvements have been made, we are unable to change the rating of this key question at this inspection. This is because there were other areas in the key question that were rated as requires improvement at the last comprehensive inspection that we did not look at during this inspection. We will check on these areas at the next comprehensive inspection.

The timing of this inspection on 27, 28, and 30 November, and 05 December 2016 was prompted by information of concern we received about the adequacy of staffing levels on some occasions. We inspected the service during the weekend and evening as well as during the day to follow up on these concerns.

We found there had been some occasions when there had not been the required number of staff at the home due to sickness and unreliability of agency staff. We were told by the acting manager and provider these issues had been resolved. At this inspection we found the staffing levels reflected the planned staffing requirements on the rota and there were enough staff to meet people’s needs throughout the inspection.

Ashcroft provides accommodation and nursing care for up to 22 people with residential and/or nursing needs, including end of life care. On the days of the inspection there were 20 people using the service.

There was no registered manager in place. The previous registered manager had left in March 2016 and had recently submitted their application to deregister as the registered manager for the service with CQC. 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 deputy manager had been acting manager since the registered manager had left.

At this inspection we found a breach of regulation because there were gaps identified in staff training and we were not assured of the provider’s competency assessments for the delivery of internal staff training. You can see the action we have told the provider to take in respect of this breach at the back of this report.

We made a recommendation in relation to the safe management of medicines as there was no guidance for staff about people’s ‘as required’ medicines. We also found that, while some improvements had been made, there was a need for other improvements to the quality monitoring and management of the service to ensure it was effective in identifying problems and learning.

Some staff did not feel well supported or well managed in their roles, and felt that their issues were not always addressed when raised. The staff team said they did not always work well together and that communication could be improved. The provider told us they thought things were much better within the staff team following a recent staff meeting.

People told us they felt safe and well looked after at the home. Staff were aware of how to raise any safeguarding issues. Identified risks to people such as falls or from skin integrity breakdown were monitored and plans were in place to reduce risk. People who were nursed in bed were checked at regular intervals to ensure their wellbeing was maintained. There were plans in place to manage a range of emergencies. There were safe recruitment procedures in place. Medicines were safely managed and there were adequate systems to reduce the risk of infection.

People were well supported at the end of life stage of their care. The home worked in partnership with a local hospice to help people and their families prepare for this time, and supported people to have as pain free and positive experience as possible. The home had the highest level of award under a nationally recognised accredited framework for end of life care.

People were complimentary about the food and said they had enough to eat and drink. Nutritional risk was monitored and plans were in place to reduce risk. People had access to a suitable range of health care professionals and staff made appropriate referrals when needed to meet people’s needs. Staff sought consent from people when offering them support. The service acted to comply with the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) where people had been assessed as lacking capacity to make certain decisions about their care and treatment

People told us they were well looked after and we observed staff to be attentive and caring. Staff knew people‘s preferences and respected people’s dignity. There was a warm atmosphere at the home. Relatives and visitors appeared relaxed and said they felt welcome. People’s care plans provided an accurate record of their care and support needs. People’s needs for socialisation were met through a range of suitable activities. There was a complaints system readily available and there had been no complaints recorded since the last inspection. People were involved in making decisions about their care and treatment.

Relatives and residents meetings were held to capture people’s experiences of care and views about the home and the care provided. The acting manager told us an annual survey was completed to obtain people’s and their relative views and the questionnaires were being sent out later that month.

After the comprehensive inspection, the provider sent us an action plan to say what they would do to meet legal requirements in relation to these breaches. We undertook this unannounced focused inspection on 27 April 2016 to check that they had followed their action plan and to confirm that they now met legal requirements.

At this focused inspection we looked at aspects of the key questions Safe, Responsive and Well Led. This report only covers our findings in relation to the focused inspection. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Ashcroft’ on our website at www.cqc.org.uk.

Ashcroft provides accommodation and care for up to 22 people with residential and or nursing needs including end of life care. On the days of the inspection we were told there were 22 people using the service.

There was no registered manager in place. The previous registered manager had retired from this post at the end of March 2016 and had taken on a quality monitoring role with the service. The deputy manager was acting as manager with a view to apply to register as manager after a mutually agreed trial period. 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.

At this inspection we found that action had been taken to improve the recording of identified risks to people. Risks to people were individually identified, assessed and monitored and we saw these records were up to date. Staff recruitment records had also been checked and missing documentation applied for or completed. The application form had now been amended to request people’s full employment history.

People’s care records were now accurate and reflected their current needs and preferences to guide new and unfamiliar staff. Staff told us they had received further training on the electronic care records and we observed they were now more familiar with how to use the system.

We have therefore changed the rating of the key question Safe and Responsive to Good in line with the characteristics for each rating.

There had been improvements to the monitoring of quality at the service. Regular audits were completed to monitor quality across the service. The provider had also introduced a system for external audits to provide additional checks on quality. However, these changes were relatively recent and we were not able to judge consistency or the reliability of these improvements at this inspection.

We have therefore not changed the rating for the key question Well Led as we need to see consistent good practice over time. We will check on this at our next inspection.

The changes in ratings in the key areas Safe and Responsive mean that the overall rating for the service is now Good.

Below is a summary of what we found. The summary is based on our observations during the inspections, speaking with people using the service, the staff supporting them and from looking at records.

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

Is the service safe?

Safeguarding procedures were in place and staff understood how to identify abuse and report concerns to safeguard people using the service. Staff received annual mandatory training including training to safely administer medicines. There was guidance for staff and systems in place to ensure the environment was well maintained and people knew how to respond if a person using the service became unwell or there was a disruption to essential services.

Accidents and incidents were reported and recorded; and these incidents were audited to identify trends and introduce preventative measures and minimise the risk of reoccurrence. Staff received health and safety training. Risk assessments were completed for each person using the service to identify such risks as weight loss due to poor nutrition or pressure sores due to immobility and these were reviewed every six months. Emergency lighting and call bell systems were routinely tested to ensure people were safe.

Is the service effective?

People's health and care needs had been assessed with their involvement. Care plans were developed to reflect the level and type of support each person required to be safe and have an independent lifestyle. People's mental capacity to make informed choices had been assessed and we saw people's relatives or advocates had been involved to ensure their best interests were considered. The service worked well with other agencies such as dentists and doctors to ensure people received care in a timely and coherent manner.

Is the service caring?

We observed that people using the service were treated with dignity and respect and we saw evidence their agreement was sought before providing care. People we spoke with said ''The staff respect my wishes and I have the freedom to come and go as I wish. If I need their support they respond quickly.'

We observed that staff demonstrated a good understanding of each person's needs and level of support they required. People we spoke with told us they felt supported by staff when they required their help but were allowed a sufficient degree of independence.

Is the service responsive?

People and relatives we spoke with told us they knew how to complain and we saw there was information available to support people raise a concern. Relatives of people using the service completed an annual satisfaction survey. Where concerns had been raised these had been responded to appropriately and improvements to the service introduced.

Is the service well led?

The service had systems in place to monitor people's satisfaction with the service. Meetings for staff, people using the service and their relatives were held to assess satisfaction with the service and ensure their concerns were identified. Although staff received regular supervision they did not receive annual appraisals to support them and identify actions required to reflect relevant regulatory and/or professional requirements.

At our visit we found that the provider had made improvements to ensure that before people received any care or treatment they were asked for their consent and where people did not have the capacity to consent, the provider acted in accordance with legal requirements. Improvements had also been made to ensure care records and other service documents were up to date and stored securely.

At our visit we found that people and relatives were involved in the care. People's needs were mostly assessed correctly and care was delivered according to their needs. Staff were recruited appropriately and the provider worked with other health and care professionals to ensure people's health, safety and welfare was protected.

However, we also found that the provider had not always assessed correctly people's capacity to make decisions and people's care records were not all accurate.

On our inspection we found that the people who used the service were involved in their care planning and received personalised care and support. Staff received support and training in different aspects of care and demonstrated an understanding of safeguarding of vulnerable adults and how to raise concerns. Care records were stored securely and were mostly accurate.