Archived: Ascot Nursing Home - Ascot

As part of this inspection we spoke with five people and three visitors. We spoke with 24 staff. We also spoke with the provider, interim manager, four external training providers and an external social worker. We looked at 31 people's records. This included, care plans, risk assessments, medication administration records and records kept in people's rooms that were used to monitor their care. We also reviewed records relating to the management of the home that included 12 staff files, duty rota and training records.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we viewed.

Is the service safe?

During our inspections in April 2014 and July 2014 we identified risks to people who use the service. We asked the provider to make improvements. At this inspection we found there had been minimal improvements to impact on the quality of the services provided to ensure people's safety.

We found there was a risk that people's care and welfare needs were not fully identified or met by the staff team. This was because people's care plans did not detail how the person wanted their needs to be met. Risk assessments identified risks associated with personal and specific health and behavioural related issues. However there was limited recorded guidance for staff to minimise those risks.

The service provided was not safe because people were not protected against the risks associated with medicines. The provider did not have appropriate arrangements in place to manage people's medicines safely.

The provider had not taken sufficient steps to improve staff training, support and supervision needed for staff to meet the mental health needs of the people who were using the service. This meant people using the service were at risk of not receiving the care and support they needed, as not all staff had the required skills to meet their individual needs and keep them safe.

Is the service effective?

Since our last inspection in July 2014 improvements had been made to improve the level of recreational activities people were provided with. However, these were not person centred to individual needs with particular reference to people who live with dementia and people with mental health conditions.

Care plans had not been developed to ensure individual needs were met and risks minimised.

Is the service caring?

People we spoke with were mostly complimentary toward the staff and the care they received. We observed both positive and negative staff interactions with people who use the service.

There was insufficient information for staff to be fully informed how to manage behaviours that were specific to individuals' that may present a challenge to the service and place people and others at risk.

Staff did not engage with people in a meaningful way to ensure people using the service felt valued and respected. Staff did not have sufficient skills to know the most effective way to support individuals who presented behaviours that placed people and others at risk whilst respecting the individuals' dignity and human rights.

Is the service responsive?

There was insufficient detail in the care plans to promote an effective and responsive individualised service for people who live in the home.

At this inspection we found the provider had taken action to improve the services for the people who live in the home. Positive joint working between the provider and external health and social care professionals had contributed to those improvements. Although there was evidence to support continual improvement to meet people's care and welfare needs and manage people's medicines we found further actions by the provider were needed to be fully compliant.

The recording of daily care monitoring records had improved since our last visit. Although we found improved care plans were needed as there was a risk that people's needs would not be fully identified or met by the staff team. This was because there were too many gaps or omissions and duplication for staff, whether agency or permanent, to use the documents effectively to support people's needs.

The provider had reviewed the service's policy for providing end of life care and improvements had been made to ensure specific guidelines were available for staff to follow. However the policy had not been finalised and we found guidance detailed within the policy had not been fully used to inform people's care plans. For example people's advanced care plans did not note what cultural or religious beliefs should be considered or details of their burial choice.

People were not supported to maintain their social, physical and mental wellbeing from daytime activities. Comments from three separate people included: 'it's alright here you have to have a sense of humour as there's not much to do', 'we use to go on picnics, but now we don't' and 'as you can see there is not a lot for us to do, we just sit around'.

People were at risk of not receiving the support they needed to manage behaviours that they may present that challenge the service.

Medicines were kept safely and available to be administered. Emergency escalation plans for people with diabetes and epilepsy were difficult to locate and incomplete therefore people were not protected against the risks associated with medicines.

The inspection team who carried out this inspection consisted of two inspectors, a specialist adviser in nursing and end of life care and a pharmacist inspector.

We carried out this inspection because we received concerns regarding a potentially serious medication error and end of life care planning through a safeguarding referral made to CQC on 27 March 2014.

We also received concerns about the quality of care planning and assessments of people's needs. This information was reported to us to us on 1 April 2014 following a review of people's care at the home undertaken by commissioners.

The provider told us that the registered manager was retiring and that they had appointed a new manager to start in August 2014. The new manager had agreed an earlier start date with the provider. This was to set up monitoring processes following the concerns that were raised. The registered manager and new manager were both present at this inspection

At this inspection we focussed on end of life care planning, including reviews of people's individual care, medications and staff training.

During the inspection, the team worked together to answer five key questions; is the service safe, effective, caring, responsive and well-led? Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service, their relatives and the staff told us.

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

Is the service safe?

We found concerns regarding medication management and the provision of people's care which could have impacted on people's safety. People were at risk of missing their medication or receiving inappropriate medication. This was because it was not stored or administered in line with guidance. Staff were not aware of all the risks associated with people's care due to a lack of training or knowledge about each person they cared for.

Is the service effective?

There was a risk that care was not effective because people's care needs were not assessed properly. The service's policy for end of life care did not contain all the information required to support people appropriately when they required end of life care. Relevant guidance and research from professional bodies was not always followed. This meant people were at risk of receiving care that would not meet their needs.

Is the service caring?

We did not look at this key question during this inspection visit.

Is the service responsive to people's needs?

People did not always receive quality care. Assessments of people's needs did not always reflect changes in their care requirements. Staff were not fully supported in their training and development to effectively assess or meet people's needs.

Is the service well-led?

The service worked with some external professionals in assessing people's needs and delivering their care. However, we found that reviews of people's needs were not carried out regularly. The home's policy for end of life care did not include reference to external professionals who may be required to assist the service in meeting people's end of life care needs.

There was no system to monitor staff training. This meant the provider could not be sure that staff were competent and able to deliver care safely and effectively.

We spoke with two relatives of people who use the service. One told us they saw staff interacting well with people when they delivered care. They said their relative was reviewed by a GP regularly. They were satisfied with the care their relative received. Another relative told us they had complained to the service in recent months when they were concerned about the standard of care they witnessed. They told us they believed improvements had been made to their relative's care. We spoke with seven members of staff. They told us they were provided with some training. However, there were inconsistencies between the different training staff said they received. Staff were not aware when or if they had received certain training.

We spoke with eight staff members, including nurses, care workers and management. Staff explained how they used a range of options to try to provide care and support as people wanted. This included talking with people and their relatives to understand their wishes, and offering choices. We observed staff treated people with respect.

One nurse told us 'There's a good level of trained nurses and a pool of seniors: there are knowledge and skills to draw on. It's well run, people are caring.' We saw people's care needs were assessed. Care and treatment was planned, and delivered in accordance with their care plan. Risks were identified and actions taken to reduce the risk of harm. Staff were aware of updates to people's care needs. One relative told us they were 'Very happy with the quality of care.'

People who use the service, relatives and staff all referred to the service as 'homely'. We saw the home was secure, but people had ample space to wander within it as they wished. Some areas were in need of redecoration, but we saw the provider had a refurbishment programme in place to address this. Appropriate checks and services ensured the home was maintained safely.

People said they felt safe and felt able to raise any concerns with staff. Staff in turn felt supported; valued and motivated.

Care records were easily accessible but care plans were not always updated to reflect the persons care needs and how staff could best support the person to help them meet those needs.

The home appeared clean, although some areas were in need of upgrading and we were told there were plans to do that work. There were policies in place for the management of infection control and most staff were up to date with their training.

There were effective systems in place for the recruitment of staff and appropriate checks were carried out before people began work at the home.

The provider had effective systems in place to monitor the quality of the service. An annual survey was carried out to seek the views of people using the service as well as relatives and other professionals. Regular quality assurance audits were carried out by the provider and action was taken to address any issues that arose.