Background to this inspection
Updated
6 July 2017
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.
This inspection took place on 2 and 3 April 2017 and was unannounced. The inspection team consisted of two adult social care inspectors.
Before the inspection, we reviewed all the information we held about the service including previous inspection reports and notifications received by the Care Quality Commission. A notification is information about important events which the service is required to tell us about by law. We used this information to help us decide what areas to focus on during our inspection. We did not request a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We gathered this information on the day.
Prior to the inspection we spoke with a nurse from the Clinical Commissioning Group and spoke with the GP during the inspection. a GP.
We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experiences of people who could not talk with us.
During the inspection we spoke with eight people who used the service, one relatives and one person’s friend. We spoke with the acting home manager, the provider, service administrator, five nurses, eight care assistants, the cook, two laundry assistants, two housekeeping staff, two activity co-ordinators, the maintenance person and two volunteers.
We reviewed records which included four people’s care plans, 14 staff recruitment files and supervision and training records medicine records and records relating to the management of the service.
Updated
6 July 2017
Ashley Manor Nursing Home provides accommodation and nursing care for up to 45 older people. The service is in a rural location near Shedfield, and provides accommodation over three floors in a converted residential dwelling. At the time of our inspection 12 people were living in the home.
We carried out an unannounced inspection of Ashley Manor Nursing Home on 2 and 3 April 2017. This was a comprehensive inspection that was carried out to check on the provider's progress in meeting the requirements required as a result of our inspection on 22, 23 and 25 November 2016. At the previous inspection continuing breaches of legal requirements were found in relation to staffing and clinical governance and a new breach was found in relation to recruitment. Following the inspection the provider sent us an action plan detailing how and by when they would meet the regulatory requirements.
At this inspection we found improvements had been made to the support provided to staff. Following our previous inspection staff had received training, supervision and appraisal to enable them to effectively undertake their roles and responsibilities. The provider had reviewed the induction for new staff and clinical supervisions were to commence for nurses in April 2017. Some time was needed for this to become part of the home’s routine staffing practices.
Following our previous inspection improvements had been made to staff recruitment. The provider had implemented safe recruitment practices and we found all the required staff pre-employment checks had been completed to ensure staff would be suitable to work in the home.
Requirements relating to clinical governance had still not fully been met. This is the process whereby a provider assesses the standards, safety and effectiveness of care delivered to people. We found some clinical audits, for example in relation to falls and infections in the home, had taken place but these had not always been accurate or effective in identifying potential risks to people’s health and welfare.
The home is required by a condition of its registration to have a registered manager. The home did not have a registered manager in place. However, the home manager had submitted their application to be registered with the CQC to ensure the provider would meet their registration requirements. 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 told us improvements had been made in the general running of the home. However, we found the provider did not have an effective system in place to ensure that clinical audits completed by nurses were always checked and the inaccuracies we found for example in relation to the falls audit had not been identified. Clinical governance systems were not operated effectively to ensure the home manager would routinely scrutinise all nursing and care decisions to ensure people received care in accordance with national best practice.
People received their prescribed medicines safely and had access to healthcare services when they needed them. People liked the food and told us their preferences were catered for. People received the support they needed to eat and drink enough.
Staff had a good knowledge of their responsibilities for keeping people safe from abuse. Care plans were based around the individual risks and preferences of people as well as their medical needs. They informed staff what support people required and we saw people were supported in accordance with their care plans.
Staff sought people's consent before they provided their care and support. Where people were unable to make certain decisions about their care the legal requirements of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS) were followed.
Staff knew people well and supported people living with dementia to manage their anxiety and agitation.
People were treated with kindness, compassion and respect and staff promoted people's independence and right to privacy. The staff were committed to enhancing people's lives and provided people with positive care experiences.
People knew how to make a complaint. People told us the manager and staff would do their best to put things right if they ever needed to complain.
We identified a continuing breach of regulations 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.