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Ashleigh Nursing Home Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 8 August 2018

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

Ashleigh Nursing Home accommodates 21 people in one adapted building. At the time of our inspection there were 17 people using the service.

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.

This is the third time the service has been rated Requires Improvement.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can see what action we told the provider to take at the back of the full version of the report.

We looked around Ashleigh Nursing Home with the registered manager and found improvements were needed. We found many furnishings, including carpets and armchairs in communal rooms and bedrooms to be stained or torn. Paintwork in many bedrooms and corridors was damaged. We found a toilet that had a broken seat and pull cords in bathrooms and toilets to be heavily stained. Bed linen, including duvets and sheets had worn thin. A majority of the shortfalls we found had not been identified by the provider in their audit of the environment.

The registered person and registered manager did not have robust and reliable systems and processes in place to assure themselves as to the quality of the service being provided. This lack of oversight about the quality of the service and the services governance, meant shortfalls and areas for development and improvement had not always been identified. Plans for development in some areas had been identified, however there were no written plans about how and when these would be implemented, who would be responsible for their introduction and the process of how they would be monitored.

There were limited formalised opportunities for the management team, nurses and staff to share information about the quality of the service, share ideas for improvement and address shortfalls and concerns as staff meetings had not taken place.

People using the service and their family members spoke positively about the care they received, which included positive comments about the atmosphere of Ashleigh Nursing Home and the friendliness and approachability of staff.

People’s safety was promoted by staff that had the appropriate training to monitor and support people to be safe. Potential risks were identified and action to reduce these was taken. There were sufficient staff to keep people safe and staff were aware of their responsibilities in monitoring people’s safety and well-being. People received their medicine and were supported by staff with the appropriate knowledge and skills in the management of medicine.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrict way possible; the policies and systems in the service supported this practice. People were supported by staff that had the necessary training and skills to provide care and support. Staff worked collaboratively with people using the service and health and social care professionals to monitor people’s health to maintain and promote people’s well-being. People's dietary requirements along with their likes and dislikes with regards to food and drink were recorded. People expressed satisfaction with the meals.

People spoke positively about the caring attitude and approach of staff. Staff promoted people's dignity and all interactions between staff, those using the service and family members were positive to ensure the best outcomes for people.

People were encouraged to make decisio

Inspection areas

Safe

Good

Updated 8 August 2018

The service was safe.

People were safeguarded from abuse as robust systems and processes were in place, which included robust staff recruitment practices.

People's safety was monitored, with risk assessments and care plans providing clear information for staff as to how people's safety was to be promoted.

People were supported and cared for by sufficient numbers of staff to ensure their individual needs were met.

People's needs with regards to their medicine were identified within their care plans and medicine management systems were robust.

Effective

Requires improvement

Updated 8 August 2018

The service was not consistently effective.

The provider’s monitoring of the premises was ineffectual. The premises and furnishings were not sufficiently maintained, which meant people’s living environment was not of a good standard.

People’s needs were assessed and were used to develop care plans, which provided information as to their needs, which included guidance on the nutritional needs.

People’s health and welfare was promoted as staff liaised effectively with health care professionals.

Staff were aware of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. People using the service, family members and health care professionals were involved in decisions about people's care and support.

Caring

Good

Updated 8 August 2018

The service was caring.

People were supported by staff that were kind and caring and who spent time with them providing reassurance, care and support.

Staff respected people's privacy and dignity and independence, which was acknowledged by those using the service and family members.

People's information was stored securely.

Responsive

Good

Updated 8 August 2018

The service was responsive.

Care plans detailed the care and support people required and were regularly reviewed and evidenced people’s changing needs were responded to.

Concerns had not been recorded, however concerns raised had been actioned.

Well-led

Requires improvement

Updated 8 August 2018

The service was not consistently well-led.

A registered manager was in post.

The provider’s and registered manager’s approach towards the monitoring of the quality of the service was haphazard. Audits were not routinely carried out or planned. Therefore, the opportunity to identify shortfalls and implement the required improvements were missed.

The providers’ and registered managers’ approach to providing and promoting opportunities for staff to comment upon the quality of the service was limited.

There was no written plan in place for the development of the service.

People’s responses to questionnaires distributed by the provider identified satisfaction with the care being provided. Family members spoke positively about the service and the care their relatives received. Staff spoke positively of the support provided by the registered manager.