Archived: Ash-leigh House

Ash-leigh House is registered with the Care Quality Commission to provide accommodation and support for up to 10 people with mental health needs. The home is located in a residential area in Eccles within walking distance of the town centre. There is one main lounge and a kitchen/dining room. There are 10 single bedrooms, two on the ground floor and eight on the first floor. There is a garden to the rear of the property and a small car park at the front. At the time of our inspection there were nine people living at the home.

At our previous inspection on 27 July and 02 August 2016, we identified multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These included person centred care, dignity and respect, safe care and treatment, safeguarding people from abuse, good governance, staffing and fit and proper persons employed. The home was rated ‘Inadequate’ overall and in four (Safe, Effective, Caring and Well-led) of the five ‘Key Questions’ against which we inspected against. As a result, the home was placed into ‘Special Measures’. This meant improvements were required or further enforcement action would be taken. At this inspection, we found significant improvements had been made in all areas, with no regulatory breaches identified.

People told us they felt safe living at the home. The staff we spoke with had a good understanding of safeguarding and how to report any concerns.

We found medication was given to people safely and staff had received appropriate training. Medication was stored in locked cabinets in the office and only staff responsible for administering medication had access to the keys.

Staff were recruited safely with references from previous employers being sought and DBS (Disclosure Barring Service) checks undertaken. The recruitment files we looked at were organised and in good order, making all required documentation easy to locate.

Each care plan we looked at contained risk assessments covering areas such as falls, mobility, waterlow (to monitor skin integrity) and nutrition. Where risks were identified we saw appropriate control measures were in place. Concerns from our previous inspection such as faulty window restrictors and the cellar door being left unlocked had been addressed. Accidents and incidents were monitored, with an analysis completed to look at any re-occurring trends at the home to prevent future re-occurrence

There were sufficient staff working at the home to meet people’s needs, although several people living at the home reported they felt an additional member of staff would be beneficial at night when people were going to bed. Following the inspection, the manager contacted us to inform us that it had been agreed for an additional member of staff to work the ‘Twilight shift’ between the hours of 7pm and 12am to provide assistance to night staff.

We saw a detailed staff induction had been introduced, centred around the Care Certificate which staff completed when they first started working at the home. Staff had received supervision with the new home manager, with appropriate records maintained. We also saw that staff had received training in areas such as Safeguarding, Medication, MCA/DoLS and Health and Safety, all of which were recorded on the training matrix. We found staff still hadn’t completed training in areas such as Infection Control, Mental Health Awareness and Challenging Behaviour/Breakaway Techniques, however following the inspection the manager sent us confirmation that this had been booked for January 2017.

At our previous inspection we had found that the staff were not working within the principles of the MCA. At this inspection, we found that this had been actioned and restrictions that had previously been imposed on people were no longer in place. The management demonstrated a good understanding of MCA and DoLS. An urgent authorisation had been submitted for one person as there had been some concerns regarding their capacity to make the decision to reside at Ash-leigh and consent to their care and treatment.

We saw people received enough to eat and drink, with people also making positive comments about the food provided at the home. People said they were able to eat foods they liked and that alternatives were available. People had specific eating and drinking care plans in place, with MUST (Malnutrition Universal Screening Tool) assessments used to assess people’s nutritional needs. People’s weights and BMI (Body Mass Index) were monitored and we saw food and fluid charts had been implemented when required.

The people we spoke with felt they were receiving good care and support. People told us they felt staff treated them with dignity and respect and promoted their independence where possible.

People felt the home was responsive to their needs. Each person living at the home had their own care plan, which was person centred and detailed people’s choices and personal preferences. Initially, we raised concerns that life history and ’10 things to know about me’ documents were incomplete in some of the care files that we looked at, however the manager confirmed following the inspection that these had been implemented.

There was a complaints procedure in place which allowed people to voice their concerns if they were unhappy with the service they received. There were no active complaints at the time of the inspection. Residents meetings were also held where people could raise concerns or discuss how to do things differently at the home.

All of the people we spoke with told us they felt the service was well-led and that they felt listened to and could approach management with concerns. There were systems in place to monitor the quality of the service such as audits, weekend spot checks, staff meetings and accident/incident monitoring.

Staff told us they enjoyed their work and liked working at the home and told us they felt there was an open and positive culture. All of the staff we spoke with confirmed that significant changes and improvements had been undertaken at the home since our last inspection.

Ash-leigh House is registered to provide accommodation and support for up to 10 people with mental health difficulties. The home is located within a residential area of Eccles within walking distance of the town centre. There are two lounges, a kitchen/dining room and a conservatory where smoking is permitted. There are 10 single bedrooms, two on the ground floor and eight on the first floor. There is a garden to the rear of the property and a small car park at the front.

We last inspected Ash-leigh House in November 2015 and rated the service as ‘Requires Improvement’ both overall and in each key question we inspected against. We also identified five regulatory breaches. These related to safe care and treatment (two parts of the regulation), dignity and respect, good governance and staffing.

During this inspection we identified 14 breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to person centred care, dignity and respect, safe care and treatment (four parts of the regulation), need for consent, safeguarding service users from abuse and improper treatment, good governance (three parts of the regulation), staffing, fit and proper persons employed and requirements as to the display of performance assessments. We also identified a breach of the Care Quality Commission (Registration) Regulations 2009 regarding notification of other incidents. You can see what action we have asked the provider to take at the back of the report.

The home was not clean, with several instances of uncleanliness around the building. The vast majority of our concerns from the last inspection in relation to infection control still remained.

We found that medication arrangements were not safe, with medication not being stored securely, placing people at risk.

We found the service still did not assess and mitigate risk well. We found several instances where risk assessments had not been put in place following incidents at the home.

The service had recruited one member of staff since our previous inspection, however appropriate recruitment checks had not been undertaken.

The home had an induction programme in place for new staff, although we found no evidence that the most recent recruit had been through this process.

We still saw no evidence of staff receiving training in areas specific to mental health services, such as mental health, challenging behavior and de-escalation techniques. We had raised this at the previous inspection. Staff still hadn’t undertaken training in the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). The manager said these courses had proven difficult to source.

We saw some evidence of staff supervision since our last inspection, however the notes from discussions were brief and only covered training completed, with no discussions about people living at the home or if staff had any concerns about their work.

The home did not always work well with other health care professionals such as the bladder and bowel service, when a person had been referred for further advice.

We observed several instances where the dignity and respect of people living at the home was compromised.

Due to some of the widespread failings within the service, we found people did not always benefit from a caring culture.

There were several missed opportunities for interaction, when staff did not to attempt to engage people in conversations about what they may have wanted to do that day.

Each person who lived at the home had their own care plan in place. However we found certain sections within the care plans to be missing, with some not providing sufficient information about people’s care and support.

Care and support provided to people was not always person centred or based around their choices and preferences.

At the last inspection we observed no activities taking place. The manager said this was because people did not want to do this, although this wasn’t clearly documented. During this inspection, we were told activities would only be funded if it was financially viable for the service.

Similar to the last inspection, we saw no evidence people were involved in the review and updating of their care plans, which were done each month.

We found no improvements had been made to ensure the quality of service was being effectively monitored by both the manager and provider. The manager told us regular checks and audits were done but not documented.

The manager had sent us an action plan from the previous inspection; however we found it to be inaccurate, with re-occurring concerns still present from the last inspection. We also identified five continuing and several additional breaches of the regulations.

We saw no evidence of any recent resident and relative meetings. The manager said they did take place but weren’t documented. The feedback from both staff and people living at the home was that they didn’t take place regularly.

We found confidential information was not stored securely, with documentation such as care plans and daily notes accessible to anybody in the kitchen or attic areas.

The home had failed to display the ratings from the previous inspection and to also notify us about certain incidents at the home, including a recent fire. Both of these failures are considered to be an offence.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains 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 the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will 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 we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

We are considering our enforcement actions in relation to the regulatory breaches identified. We will report further when any enforcement action is concluded.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people who used the service, their relatives, and the staff supporting them and from looking at records.

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

Is the service safe?

We spoke with four people who used the service during our inspection who told us they were treated with respect and dignity by staff at all times. People told us they felt safe and comfortable in the presence of staff. The home had systems in place in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards although no applications had been submitted to the local authority. This means people were safeguarded as required.

Systems were in place to ensure managers and staff learnt from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve.

A staffing rota had been compiled, maintained and evidenced there were enough skilled and qualified staff to safely meet the needs of people who used the service. Managers ensured people's care needs were taken into account when making decisions about the numbers, qualifications, skills and experience required for carers. This helped to ensure people's needs were always met.

We found medication practices were safe and thorough. We observed medicines to be locked in secure cupboards and were clearly separated into medication to be given in the morning, at lunch time and in the evening. Each person we spoke with was aware of when they needed to take their medication and commented staff were prompt in doing this. There were people who lived at Ash-Leigh house who were able to self-medicate. Staff told us this would be appropriately risk assessed if this ever changed.

Is the service effective?

There was an advocacy service available if people needed it, this meant that when required people could access additional support.

People's health and care needs were assessed with them, and they were involved in writing their plans of care. Specialist dietary, mobility and equipment needs had been identified in care plans where required. Two people we spoke with told us their care plan was reviewed each month and could change certain aspects of their support if required.

People's needs were taken into account with signage and the layout of the service enabling people to move around freely and safely. The premises had been sensitively adapted to meet the needs of people with physical impairments.

Is the service caring?

People were supported by kind and attentive staff. On the day of our inspection we observed staff speaking with people in a caring manner were patient and understanding in respect of their varying support needs. People commented, 'I've lived here for two years and I am happy. I'm a lot calmer here and the staff are good. I'm supported with cooking, taking my tablets and domestic tasks. I like to go out when I can and go into town. I have no complaints'. Another person told us; 'I'm happy. I have routine and I'm able to follow it whilst living here. I have my independence and the staff respect that. I can come and go as I please'.

People's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people's wishes. We noted risk assessments had not been reviewed for some time. Some were done in 2009 and others in 2011. We discussed this with the deputy manager who ensured us a full review of all risk assessment would be undertaken following our inspection. This would ensure potential risks to people who used the service were being regularly monitored by staff to keep them safe.

Is the service responsive?

The people we spoke with told us they had access to a range of activities in and outside the service regularly. People told us they were supported by their carers to attend appointments in the local community when required.

There was a complaints procedure in place. People knew how to make a complaint if they were unhappy but had never been given reason to. People can therefore be assured that complaints are investigated and action is taken as necessary when required.

There were other various quality assurance systems in place. These included the sending of regular surveys to people who used the service and through regular discussions during the monthly care plan review process. We asked how feedback from people was then acted upon and we were told this was then discussed during residents meetings or discussed directly with the person concerned.

Is the service well-led?

The service worked well with other agencies and services to make sure people received their care in a joined up way.

The service has a quality assurance system, records seen by us showed that identified shortfalls were addressed promptly. Quality assurance systems included surveys, house/staff meetings and monthly care plan reviews. The deputy manager told us at present, there was no quality audit system in place and this was something they would look to introduce following our inspection. This would further enhance the monitoring of the quality of service provided.

The staff we spoke with were clear about their roles and responsibilities and told us they developed good relationships with people who used the service over time. This helped to ensure that people received a good quality service at all times.

People looked well groomed. Staff were observed encouraging people to be as independent as possible and this was done in a sensitive and respectful manner.

We spoke with a health professional who visited the home on a regular basis, they had no concerns about the care and support people received.

We walked around the building and saw that bedrooms, bathrooms and lounges had been redecorated. People's bedrooms were personalised with photographs, ornaments and soft furnishings.

We looked at a sample of staff recruitment files and saw that relevant safety checks had been carried out before people started work. We saw that staff had undergone an induction when they started working at the home.