Archived: Ashdown Residential Home

Ashdown Residential Home, referred to in this report as Ashdown, is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Ashdown is registered to accommodate up to 12 people with learning disabilities, mental health and complex needs in one adapted building. Nursing care is not provided by staff at Ashdown. This is provided by the community nursing service. At the time of this inspection in March 2018 there were 11 people living in the home.

The service had a registered manager. 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 our last inspection in March 2016 we rated the service good. At this inspection in March 2018 we found the evidence continued to support the rating of good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

At this inspection we found the service remained Good.

Although the care service had been developed and designed prior to Building the Right Support and Registering the Right Support guidance being published, it followed these values and principles. These values related to people with learning disabilities using the service living as ordinary a life as any citizen. They achieved this by promoting enablement, independence, choice and inclusion. They demonstrated how they delivered person-centred care and how they ensured people had easy access and include to the local community.

At the time of our inspection in March 2018 people living in Ashdown were living with learning disabilities along with varying physical and mental health needs. People’s level of need was varied, with some people being able to leave the home independently and others requiring support to do so.

Staff treated people with kindness and respect. The atmosphere at the home was jovial with people clearly enjoying each other’s presence. Staff knew people’s preferences and communicated with people using their preferred methods of communication. We found staff had caring attitudes towards people and spoke highly of them, their personalities and qualities.

People spoke highly of the care and support they received at Ashdown. Comments from people included “I’ve never had it so good”, “I couldn’t get better help anywhere else” and “I’m one of the lucky ones to be here.”

Staff had a good understanding of the Mental Capacity Act 2005 (MCA) and put it into practice. Where people had been unable to make a particular decision at a particular time, their capacity had been assessed and best interests decisions had taken place and had been recorded. Where people were being deprived of their liberty for their own safety the registered manager had made Deprivation of Liberty Safeguard (DoLS) applications to the local authority.

People who lived in Ashdown were protected from risks relating to possible abuse, to their needs and their health conditions. Staff knew how to recognise possible signs of abuse. Staff had assessed individual risks to people and had taken action to minimise these. Where accidents and incidents had taken place, these had been reviewed and action had been taken to reduce the risks of reoccurrence. Staff supported people to take their medicines safely and staff knowledge relating to the administration of medicines were regularly checked. Staff told us they felt comfortable raising concerns.

Recruitment procedures were in place to help ensure only people of good character were employed by the home. Staff underwent Disclosure and Barring Service (police record) checks before they started work. Staffing numbers at the home were sufficient to meet people’s needs. Staff had the competencies and information they required in order to meet people’s needs. Staff received sufficient training as well as regular supervision and appraisal.

People were supported to have enough to eat and drink in ways that met their needs and preferences. People were supported to make choices about what they wanted to eat and encouraged to help prepare meals where they were able.

There was open and effective management at Ashdown. People, relatives, staff and healthcare professionals were asked for their feedback and suggestions in order to improve the service. There were effective systems in place to assess, monitor and improve the quality and safety of the care and support being delivered.

Further information is in the detailed findings below.

This inspection took place on 31 March 2016 and was unannounced. The previous inspection of the service had taken place on the 7 August 2014, when the service was not meeting standards in relation the management of environmental risks, for example from unprotected hot surfaces. The provider sent us an action plan telling us what they had done to put this right. On this inspection we checked and saw that improvements had been made.

The service had a registered manager. 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 registered manager had changed since the last inspection of the service.

Risks to people’s health and well-being had been assessed and actions recorded on how the service was mitigating the risks. Improvements had been made to the safety of the home, for example with the provision of hot surface protection. The home had employed a maintenance person and systems for responding to maintenance issues had improved. The premises had been adapted to meet people’s needs and wishes, and provided a comfortable environment. All areas seen were clean, comfortable.

People said they were cared for well, and we saw people interacting positively with staff and being treated with respect. Staff understood their responsibilities with regard to safeguarding people, had received appropriate training and there were policies and procedures in place to help staff identify and report abuse. Staff received the training they needed for their job role and were knowledgeable about people’s care needs. Staff were positive about the changes they had supported people to make in their lives. Staff took care to support people with their clothing and personal grooming in accordance with their wishes.

People were supported by sufficient numbers of staff. Staff were flexible with their shifts to meet people’s needs and interests outside of the home, for example in attending clubs in the evening. Staff were employed following a full recruitment process, and updated information annually, for example to confirm they had not been convicted of any offences.

Medicine practices were safe. Staff understood how people’s medicines needed to be stored and administered in line with the prescribing instructions.

People’s rights were being protected. The service was supporting people in line with the Mental Capacity Act. Assessments of decisions made in people’s best interests were being carried out, including consultation with relatives or other advocates where appropriate but were not always recorded in line with the principles of the MCA. We found people had not been disadvantaged by this, and the areas we looked at were not unduly restrictive. People’s communication was supported and understood. Staff learned the signs people used to communicate and were making information more available to people in formats they could understand.

People had access to community healthcare professionals, to support their healthcare needs. A community healthcare professional told us the home was managing people’s healthcare needs well. Where additional medical support was needed this was quickly accessed, for example with people taken to hospital appropriately when their needs increased. Support had been given to help people feel more comfortable about attending medical appointments where people had expressed anxiety about this. People were supported to make choices about meals and help prepare food with support if they wished. People were being supported to follow healthy eating principles, and lose weight if they wished to do so.

People were supported to live their lives the way they chose, and their preferences and choices were respected. Care files and plans reflected people’s needs and aspirations. Plans for emergency support such as for people with epilepsy were clear and were understood by staff. People followed activities of their choice. The home was a busy and active place. For people with increased needs, for example who did not leave the home, staff ensured they spent time with them regularly, and had frequent checks to ensure they were kept comfortable.

People were confident that any complaints or concerns would be managed well. The registered manager of the service was well liked and respected by staff and people living at the service. They were able to manage the service effectively, and had appropriate levels of responsibility and accountability for their role. Records were well maintained, and systems were in place to ensure the registered manager was aware of areas that needed to improve through a series of audits.

People were involved in having a say about the service, and improvements were made as a result of their comments and suggestions. Quality assurance and quality management systems were in place to ensure people received a consistent high quality experience of their care.

We recommend the service takes advice from a reputable source on the management of laundry workflow systems to reduce the risks of cross infection.

This inspection was carried out by an adult social care inspector. During the inspection we looked at the evidence to answer five key questions:

Is the service caring?

Is the service responsive?

Is the service safe?

Is the service effective?

Is the service well led?

Ashdown is a care home without nursing providing care and support for up to 12 older people with a learning disability. Some of the people who live there are also living with a dementia associated with their learning disability.

We spoke with or spent time with five of the eight people who lived at the home. We also spoke with four members of staff and two members of the management team. We reviewed records relating to the management of the home which included four care plans in detail and observed the care and support people received.

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.

Is the service caring?

We found that the staff were caring. We saw that staff at the home took time to ensure people's personal grooming was in accordance with their wishes, to enhance their individuality, self-esteem and confidence. One member of staff told us about how they supported one person to ensure their hair was coloured the way they liked it and their clothes were colour co-ordinated. We spoke with this person who told us that the staff were kind and helped them. They told us 'Staff do what I ask them to do. Yes.'

We saw staff supported people well. We saw a member of staff sitting with a person who had a visual impairment. We saw they supported and communicated with them well, and helped them to use the sound functions on a tablet computer. Both were laughing and enjoying the shared experience. This showed us that staff understood and worked well with people's needs.

We saw that on the day of the inspection the home was celebrating one person's birthday. We saw and heard staff celebrating with the person and involving others in the event. We saw that people had celebrated with a birthday buffet and cake. This helped the person retain a sense of their individuality and acknowledged their personal celebrations.

Is the service responsive?

We saw that the home had responded well to the changing needs of the people who lived there. Some people had lived at the home for over 25 years, and had become physically frail or had developed a dementia associated with their learning disability. We saw that the home had accessed specialist equipment to support people's moving and handling needs, including hoists and specialist seating and mobility aids. We saw that staff had undertaken training in dementia and were putting this into practice to help support people. For example we saw one person using a sensory apron during our visit. This contained items of different textures and shapes so that the person had something to engage with at a sensory level if they wished.

We saw that where people were able to express an opinion or request this was acted upon. For example we saw that the home had responded to people's requests for regular takeaways. We also saw that the home responded to one person putting on weight by encouraging them to attend a healthy living group.

Is the service safe?

We found that people's care was risk assessed and appropriate actions taken to reduce or remove risks where possible. For example we saw that one person had been assessed as being at risk of choking or inhaling food while eating. Staff had received specialist training to support the person with their eating. An assessment had been carried out by the speech and language team and thickeners for liquids prescribed along with a detailed care plan in place. This had helped the person to eat safely and reduce risks.

However we also saw that risk assessments had not been carried out for the environment. Where risks had been identified they had not always been addressed in a timely manner. For example we found that three fire doors had been reported as not closing properly on six occasions since December 2013. These were still not closing properly at the time of the inspection. This left people at risk should a fire break out.

Is the service effective?

The effectiveness of the service was challenged to some extent by the wide variation of the needs of the people who lived there. For example some people were living with advanced dementia associated with their learning disability, which left them in need of total care. Other people were able to go out into the local community unsupported. We saw that staff understood people's needs well and there were effective communication systems in place to ensure information was transferred between staff.

We saw people were comfortable at the home and in staff company. We saw people's care plans were being actioned and people were being supported to develop their potential effectively. People we spoke with said they liked living at the home. One person told us 'It's good here. We are friends'.

Is the service well led?

Prior to April 2014 Ashdown was subject to a safeguarding process due to significant concerns over the operation of the home. The Care Quality Commission had taken enforcement action against the home. The home recruited an experienced Registered Manager who has worked hard to ensure improvements were made and sustained at the home. The Registered Manager had a clear idea of the ethos and philosophy of care they wished Ashdown to provide.

We saw that there were clear systems for auditing the quality of the service and making improvements. However we also identified a concern that the Registered Manager might not have the delegated authority to ensure that all risks at the home were managed effectively.

We had made compliance actions and served warning notices on the provider at visits in April and May 2013. We carried out follow up visits in July, August, October and December 2013. On our December 2013 visit we found that the provider had made improvements in some areas. These were for quality assurance and record keeping. A qualified and experienced registered manager had also been appointed.

At this visit in March 2014 we found the provider had made further improvements. People's consent for care was being sought and recorded. Care workers were receiving support to carry out their roles effectively.

We spoke with three people who used the service. All of them were satisfied that choices had been offered to them by care workers. One person told us "I get a choice of what I want to eat'. Another person said 'I can't read but I can point to pictures and say 'I want that'.

We found evidence that care workers had received regular supervision meetings with their manager. One care worker told us 'I feel supported by the manager, it's a good place to work.'

At this visit in December 2013 we found the provider had made improvements. A new manager had been been appointed in September 2013. The new manager had made significant changes since our last inspection.

We spoke with two people who used the service and two relatives who were visiting at the time of our inspection. One relative told us 'I now get asked my views and I have provided feedback about Ashdown.' We also spoke with the new manager and three care workers.

We saw that a range of quality assurance checks and audits had been put in place by the new manager which ensured that care and safety was now being monitored. Staff told us that they felt supported by the new manager and that they understood the new systems in place.

There had been a significant improvement in the care planning for people who lived at the home. We found that care plans for all nine people who lived at the home had been updated since our last inspection.

We looked at a range of records which were now being kept and found the majority of them to be accurate and up to date.

At this visit in October 2013 we found the provider was still non-compliant with four essential outcomes. This meant that people remained at risk of poor quality care. We found that since our visit in February 2013 the provider had failed to ensure that the service had provided the minimum standard of care that could be expected.

We found that people's consent had not been obtained for care and treatment provided to them by the home. For example, there was no evidence to show whether people's consent had been sought for their personal care or daily activities.

There had been no significant improvement in the care planning for people who lived at the home. We found that care plans for eight people who lived at the home had not been updated since our August 2013 inspection. This meant that people remained at risk of not having their needs correctly assessed and met.

We found the provider did not have effective systems to assess and monitor the quality of the service that people received.

We found that since our visit in February 2013 the manager (also the provider) had failed to ensure that the service had provided the minimum standard of care that could be expected.

There had been no significant improvement in the care planning for people who lived at the home. This meant that people were at risk of not having their needs correctly assessed and met. We saw that some risk assessments had been completed in relation to malnutrition. However, the subsequent records did not show if the person had continued to, or had become at risk of malnutrition.

Staff told us they did not feel supported by the manager and did not receive regular supervision.

We found that people's consent had not been obtained for care and treatment provided to them by the home. For example the provider told us he had not recorded any information for people living at the home to gain their consent to treatment or care.

We saw that medication storage areas were clean and free from build-up of excess stock. We saw that medication had been administered safely and stored securely.

We found that workers were not well supported. For example we found care workers had not received regular supervision or appraisals. One care worker had not received supervision since 30 April 2011.

We found the provider did not have effective systems to assess and monitor the quality of the service that people received. For example incidents and accidents that had happened at the home had not been analysed or monitored to assess how to prevent people from further accidents injury in the future.

We saw that the home did not have accurate or well maintained records. Including people's personal records and medical records .

During the February inspection we also found moderate concerns. The provider submitted an action of how they intended to put things right.

During our April 2013 inspection we noted that some actions had been taken. We continue to have some major and moderate concerns.

Arrangements to ensure that people's privacy and dignity were respected had been improved.

Arrangements had not been put in place to ensure that decisions made on behalf of people had been done so in their best interests.

Not all the health care needs of people who lived at the home had been met.

Procedures for the safe management of people's money had improved. Arrangements were not in place to show that people had been involved in making decisions about how they spent some of their money.

Systems were not in place for the safe management of medication.

Staffing levels had been improved since the last inspection.

The deputy manager had started to undertake individual supervision sessions for all staff.

Arrangements to undertake quality assurance audits at the home had not been put in place.

Reco

We followed up on the improvements required at this inspection. We judged that the provider had made improvements and the home met the regulations and outcomes expected. We visited the home and carried out the inspection on 19 March 2013.On the day of our inspection 10 people were living at the home and receiving care from the service. We spoke with 3 people, the provider (owner) who is also the registered manager, the deputy manager and two care workers. We spent time observing care and looked at three care plans. We checked how people were looked after at each stage of their care.

The home had made obvious improvements since the last inspection. Not all of the people who lived at the home were able to discuss their experience in detail with us [the CQC]. However, all made positive comments about the service. One person said 'Things are fine' and two other people gave us the thumbs up sign.

The provided had reviewed and improved the procedures followed at the home to ensure that people had been protected from the risks of financial abuse.

During our visit we spoke with eight people living at Ashdown and with six staff and the manager. Some people could not talk with us, so we observed care and interactions between staff and people.

We found that staff were making decisions on behalf of some of the people who lived at Ashdown without obtaining or recording valid consent. We also found there was no written evidence that people with dementia had been in how their care was delivered.

We found that some people had not experienced care, treatment and support that met their needs. People were not protected against the risks associated with medicines because appropriate arrangements were not in place to manage medicines.

People described staff as 'nice' and kind'. We found there were not enough staff on duty to meet people's needs. There were no staff on duty at night, although the owner was available. Staff were not effectively supported to develop the skills needed to meet the needs of people using this service. Staff did not always ensure that people's privacy, dignity and independence were respected.

The provider did not have effective systems for identifying and managing risks to the health, safety and welfare of people who used this service.

Since this inspection we have made a referral to Devon Safeguarding Adults team and to Devon Fire and Rescue services about our findings at the home.