Archived: Ashbourne House - Torquay

Ashbourne House – Torquay is a residential care home for older people. It is registered to accommodate a maximum of 28 people. On the days of our inspection there were 21 people living at the service. The service provides care and support for people living with dementia. The service also offers a day care facility.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

The provider managed the service and was registered with the Care Quality Commission. 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.

Prior to our inspection the Commission had been advised by the local authority that two safeguarding alerts had been raised. Concerns related to staffing levels, people not always being kept safe from avoidable harm or abuse, the training and competence of staff, and the management and leadership of the service.

People and their relatives told us there were not enough staff to meet their needs. Staff told us they felt pressurised and explained they were struggling to meet people’s personal care and social care needs. The provider and manager recognised more staff were needed and were taking action, but had faced a delay in obtaining employment checks for some people. At the end of our inspection on day one, the provider was reviewing their day time staffing levels and had increased their staffing levels at night.

People received care from staff who had undergone training to meet their needs. However, essential training, such as dementia care had not been undertaken by staff, but the provider told us this had been booked for October 2016. Staff were not supported and supervised to ensure people’s needs were met effectively. Staff told us they did not feel supported by the manager or provider, telling us they did not feel they listened to their concerns about the current staffing pressures they faced and the impact that this was having.

People told us staff were kind. Staff, interacted with people in a kind way but were observed to be rushed in their approach, and predominately focused on tasks. People’s friends and relatives could visit at any time and were made to feel welcome. People’s privacy was respected.

People’s dignity was not always promoted. People appeared unkempt. Relatives commented that sometimes their loved one was found to be wearing other people’s clothes, and that their clothing had not been changed for a number of days.

People were not protected from risks associated with their care. People did not always have risk assessments in place, and staff did not know how to meet people’s moving and handling needs safely. Risks associated with people’s nutrition and hydration, were not being effectively monitored to help ensure prompt action was taken when necessary. Risks associated with people’s skin were not being managed to help reduce the likelihood of people developing pressure sores. Accident reports and records were not always legible or detailed. This meant the provider was unable to effectively investigate incidents, to be able to put plans for improvement into place.

The provider had environmental risk assessments in place to identify how risks should be managed to ensure people’s safety. However, action had not been taken to address previous environmental concerns raised at our inspection in July 2014.

Moving and handling and fire equipment was serviced in line with manufacturers’ guidelines, to ensure it was safe to be used. People had personal emergency evacuation plans (PEEPs) in place which meant emergency services could be informed of how people should be assisted in an emergency, such as in the event of a fire. Thermostatic valves ensured the water temperature was regulated so people did not burn themselves.

People were not protected from avoidable harm and abuse, because the provider did not learn from mistakes and staff did not fully understand safeguarding procedures. People were not always protected from infection control practices to help prevent and control the spread of infection. Infection controls audits had not helped to highlight when improvements were required.

People were supported with their medicines in a respectful manner; however people’s care plans did not always provide details about their medicines. This meant staff may not know how people needed to be supported. People’s medicines were not always recorded accurately when administered which meant it was not clear if they had been given the correct dose. Monitoring checks did not always highlight where improvements were required. People had access to health care services to support them with their ongoing health and wellbeing.

People’s human rights were not protected because the manager and provider had a limited understanding of their responsibilities in relation to the Mental Capacity Act 2005 (MCA) and associated Deprivation of Liberty Safeguards (DoLS). Where decisions were being made for people, there was no evidence to show that a best interests process had taken place to ensure the least restrictive options were considered. People’s consent to care was asked for prior to the person being supported, however people’s care plans did not document their consent to the care and support they were receiving.

People enjoyed the meals provided, however, people and their loved ones had not been involved in the creation of the menu which meant people’s likes and dislikes were not always being considered. People’s nutritional care plans were not always up to date and reflective of the support they needed, which meant people may not be supported correctly. People’s care plans did not always prompt staff to take responsive action to help ensure people were effectively supported with their nutrition and hydration, and to ensure that concerns were escalated to healthcare professionals when necessary.

Pre-assessments were carried out prior to a person moving into the service. However, the recent pre-assessments had failed to take into account the staffing pressures at the service and that staff had not undertaken dementia training. The admission of new people had therefore placed a further pressure on the service and had negatively impacted on the care and support people already living at the service received.

People did not receive personalised care which was responsive to their needs. People had care plans in place, but care plans were not up to date and reflective of the care they required. This meant staff did not have the correct information to provide safe, effective and responsive care to people.

Care plans which had been created by external healthcare professionals were not always followed to ensure people’s needs were met. People, who were cared for at the end of their life did not have care plans in place. This meant staff did not have information about what people’s wishes and preferences were to enable them to provide personalised care and support.

People’s care plans had not been created with the person or their families to ensure they reflected their wishes and preferences. People, living with dementia did not have care plans to inform staff of the best way they should be supported. People had little to do through-out the day to occupy themselves. Social activities were limited.

People’s complaints were not always effectively listened to and resolved, and complaints were not always used to improve the service. The provider and manager told us they would reflect on how they had handled previous complaints, in order to make improvements.

There was a management structure in place which included the provider and manager. However, the manager was unable to manage the service effectively because they had been working as a member of staff, due to staff shortages. Relatives, staff and some external health and social care professionals told us they did not feel the service was well-led; and the findings of our inspection also demonstrated the service did not have effective leadership.

The provider had some systems and processes in place to help monitor the quality of care people received. However, the tools which were in place had not identified areas requiring improvement and people’s

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 looked at.

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

Is the service safe?

People were cared for in an environment that was safe, clean and hygienic. Equipment at the home had been well maintained and serviced regularly. There were enough staff on duty to meet the needs of the people living at the home and a member of the management team was available.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. One application had been submitted to the Local Authority but had not been approved. Proper policies and procedures were in place and relevant staff had been trained to understand when an application should be made.

Is the service effective?

People told us that they were happy with the care they received and felt their needs had been met. It was clear from what we saw and from speaking with staff that they understood people's care and support needs and that they knew them well. One person told us "They are well up with what to do".

We found care and treatment had been planned and delivered in a way that was intended to ensure people's safety and welfare. For example, we saw a comprehensive assessment of people's needs and a range of risk assessments had been completed.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers were patient and gave encouragement when supporting people. People told us they were able to do things at their own pace and were not rushed. Our observations confirmed this. One person told us "They (staff) treat everyone with TLC".

We saw that when people had been assessed at being at risk of not drinking or eating, food and fluid charts were being maintained. We saw that people were encouraged to drink over 1litre of fluids each day and that amounts were totalled to show how much people drunk over the day. We heard staff encouraging people to eat and offering choices of food. Where people were reluctant to eat we saw that staff went back several times to encourage people.

Is the service responsive?

Records confirmed people's preferences, interests and diverse needs had been recorded and care and support had been provided in accordance with people's wishes.

There were arrangements in place to deal with foreseeable emergencies. For example, staff had received training in first aid and there were first aid boxes available around the home. People told us that there was a variety of activities and entertainments on offer. They told us that there were also regular outings.

The provider took note of reports prepared by the Commission following an inspection. We know this because following our inspection in March 2014 the provider made the required improvements to the building and staffing assessments.

Is the service well-led?

The provider protected people who used the service and others who may be at risk, against the risks of inappropriate or unsafe care and treatment. We know this because there was an effective system in operation which was designed to enable the provider to regularly assess and monitor the quality of the services provided.

People that we spoke with all told us that if they had any concerns they would raise them with staff or the Registered Manager. One person told us they never had any major concerns, but anytime they had raised concerns they (staff) 'always get things sorted'. Another person told us 'All the time they are asking if you are happy'.

People told us that regular meetings were held with the Registered Manager. People said they were able to raise any concerns, or make suggestions. One person told us they had asked if the Wednesday outings could be in the afternoon rather than the morning. The Registered Manager told us that they had not had time to rearrange this but that they planned to do so.

The information of concern related to inadequate staffing levels and staff training, poor infection control, maintenance and upkeep of the building, poor medication practice, lack of choice for people living at the home and poor nutritional standards.

We found that people living at the home did have choices in their lives and we saw staff treating people with respect.

We found staff understood people's needs well. However, we found that on this inspection there was still not a formal system in place to assess the number of care hours or skills mix required. Staff that we spoke with told us that they did not have enough time to provide care to people, particularly at weekends, in the afternoons or where people needed two care workers to support them. We found this put people at risk as staff were not following care plans or risk assessments at all times.

We found that staff had been employed following a full recruitment process; medication was administered appropriately and the home was clean. However we found that areas of the premises needed attention, including to remedy access problems, worn carpets and decor.

We found staff received training and support to enable them to carry out their role, but that some had not been updated.

We found that people were being supported well. The staffing levels were pressured at times but we saw that people received the care and support they needed. We saw many areas of good practice, with particular regard to activities and stimulation available. We saw many people were engaged in the local community. A care worker told us 'I can put my hand on my heart and know absolutely that the people here have a good quality of life'.

The meals we saw were presented well. Measures were in place to monitor and address concerns over people with poor food intake.

People we spoke with who were able to speak told us they were happy with the home. We saw care workers spent time engaging with people who could not communicate verbally to ensure their needs were met.

We found there were systems in place to manage the quality of the service. A new manager has been appointed to be in day to day charge of the home.

We (the CQC) spoke with three people, two relatives, the provider (owner), registered manager/provider and three carers. We also spent time observing care and lunch time and looked at four care plans. During our two day inspection a maximum of 18 people were living at the home and receiving care from the service.

One person told us that the staff 'were all on the mark' and were 'very good". They described the staff as 'all very kind' and said 'I can speak to anybody.' Another person said 'It's lovely here. I get on well with the staff.'

Staff showed consideration and respect in the way they responded to the needs of people with dementia. There were enough staff to meet people's needs and staff were well supported.

All the people, relatives and staff we spoke with were positive about the cleanliness of the home. Significant improvements had been made to the premises. Medicines were administered safely.

The provider had a lead role in quality assurance systems and there was evidence of a commitment to a culture of openness and continual improvement.