Ashfield Nursing Home

People's experience of using this service and what we found

The service was not always safe as the home was not sufficiently cleaned and maintained to a high standard. The provider reacted to issues and concerns, but not in a timely manner. The provider did not ensure that there were good quality and governance processes in place to support improvements to the service.

Risks relating to people’s personal and nursing needs were assessed and managed with detailed risk assessments in place to ensure staff cared for people safely.

People were supported by sufficient and skilled staff. People’s medicines were administered in a safe way. Safety measures and systems were in place to ensure people were kept safe.

Managers and staff had clear understanding of people’s needs. Relationships with other professionals were consistent.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was Good (published 10 June 2019).

Why we inspected

We undertook this focused inspection as the local authority raised concerns with regards to the infection control process within the home.

This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements. The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed. This is based on the findings at this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Follow up

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified two breaches in relation to the premises and equipment and good governance at this inspection.

We will continue to monitor information we receive about the service until we return to visit as per our reinspection programme. If we receive any concerning information we may inspect sooner. You can see what action we have asked the provider to take at the end of this full report.

The service had a registered manager in place at the time of the inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

People’s experience of using this service:

When we previously visited the service in October 2018, we found concerns with staffing and staff training, medicines management, governance and oversight of the service. At this inspection we found significant improvements had been made in these areas. However, there were still improvements to be made with the environment. There was a lack of communal areas to support people who needed quiet and privacy. People’s rooms lacked personalisation and a lack of seating to allow people and their relatives sit. Organisation at mealtimes meant people were not always supported in a consistent way. Signage at the service required further improvement to make information accessible for people.

People were safe and protected from abuse, appropriate measures were in place to manage safeguarding incidents. There were processes in place to ensure learning from events. Risks to people safety were well managed, staffing levels met the needs of people at the service.

Medicines were well managed; the service was clean and staff had a good knowledge of Infection prevention and control.

Nationally recognised assessment tools were used to support care and staff received appropriate training for their roles. People’s health needs were well managed and there were good relationships with health professionals that had a positive impact on people’s needs.

Staff gained people’s consent before providing care. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible: the policies and systems in the service supported this practice. People were supported to express their views and opinions about their care.

Staff showed a caring attitude towards people and the interactions we saw were positive. Staff were respectful and worked to maintain people’s privacy and dignity.

Care plans contained good information on people’s needs and social activities were in place. People’s complaints and concerns were dealt with appropriately and people’s end of life needs were supported.

We were consistently told the management team were open and approachable. The registered manager listened to staff and worked to improve the quality of the service. The provider had employed a Quality Compliance Manager and the quality monitoring processes had a positive effect on improvements at the service. Staff were supported with regular supervisions. The management team worked with external professionals to improve the quality of the service.

Rating at last inspection: When we last visited the service in October 2018 we inspected two key questions Safe and Well Led at that inspection the rating for those key questions was Inadequate

Why we inspected: We undertook this comprehensive inspection to follow up on our previous inspection, assess the risk to people living at the service and provide a rating for the service.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

The inspection visit took place on the 4 October 2018. It was unannounced and was planned as a focused inspection, in response to concerns that had been raised with us since the last comprehensive inspection in July 2018. After that inspection we received concerns in relation to staffing levels, unsafe care, poor management and the impact on people using the service. As a result, we undertook a focused inspection to look at safe and well led. This report only covers our findings in relation to those areas. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Ashfield Nursing Home on our website at www.cqc.org.uk.

At this inspection we found continued breaches of Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014; plus, a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

The team inspected the service against two of the five questions we ask about services: is the service safe and is the service well led. This is because we were concerned the service was not meeting some legal requirements. No risks, concerns or significant improvement were identified in the remaining Key Questions through our ongoing monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

Since the last inspection, there had not been sufficient improvement in the overall governance of the service. The management of medicines, infection control and staffing had continued to deteriorate and the service is now rated inadequate and means the service is 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 enough improvement is not made within this timeframe and 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 and 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.

On the day of inspection there was no registered manager in post. The previous registered manager left in August 2018 and de-registered with the CQC. However, the new manager, who was present throughout the inspection, was in the process of completing their registration with us. They were also supported by the provider and a registered manager from another service managed by the provider. 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.

There was a whistleblowing policy in place and staff knew how to escalate concerns to external organisations if they were concerned about people’s care. The manager had notified us of two safeguarding incidents. However, we found more incidents where people had been at risk of harm that had not been notified to us and it was not clear whether information had always been shared with the local authority or safeguarding team.

Risk assessments were in place for many aspects of care, but they were not always robust and were not always updated promptly after an incident or change of circumstances. Daily records were not completed contemporaneously. This meant staff did not always have access to up-to-date information and we were not assured that people received their planned care.

The manager told us that people needed 10 staff to meet their dependency needs. We checked the rota for October and found there was not 10 staff on any day of the month. We also found that some staff included in the rota were not able to provide personal care as they were new and had not completed their induction or provided all necessary pre-employment checks. This meant there was not enough trained and experienced staff on duty to meet the identified needs of people.

Processes regarding storage, administration and recording of medicines were inadequate. Medicines were not stored safely. One medicines room was not fit for purpose as it was too small and unhygienic. There were no hand washing facilities in the room and we found records and unused medicines discarded on the floor.

Medicines were not always administered safely. We found medicine errors in all three medicine records we looked at. These errors included – missed medicines, not administering the dosage prescribed and unsafe practice regarding covert medicines (hidden in food or drinks). Audits of medicines were not completed.

There was a history of non-compliance in respect of infection control and we found cleaning was still not a good standard. We found unclean communal toilets and offensive odours in people’s rooms and communal corridors. The provider had not made the improvements required from the last inspection to make surfaces more hygienic and easier to clean; apart from one shower room which had been renovated.

The service was not well led. The provider had not provided the management and resources necessary to make the improvements identified at the last inspection; and had been rated ‘requires improvement’ in well led, at the last three inspections. There was no registered manager in post. However, the new manager had been in post for nine weeks and was in the process of completing the registration process with CQC.

Quality assurance was inadequate and had not identified where improvements were required. For example, they had not identified medicine errors and inadequate cleaning. Many areas for improvement identified at the last inspection were incomplete which indicated they had not been well managed.

Information regarding risks to people was not always shared with relevant organisations and we did not always receive notification of incidents where people were at risk of harm.

Contingency plans in place to ensure the service was adequately staffed during this period of staff change, were not effective. The service was frequently understaffed in respect of the providers dependency tool, which concluded they required 10 staff on duty to meet people’s needs. This impacted on the providers ability to implement their improvement plan as they were now focused on staff recruitment and induction.

Healthcare practitioners who worked in partnership with the staff at Ashfield Nursing Home, said staff responded positively to feedback and followed guidance given to them about how to meet people’s individual care needs. They said staff did a good job caring for people with complex needs and in difficult circumstances.

Accommodation for up to 40 people is provided over two floors in two separate units. There were 39 people using the service at the time of our inspection. Ashfield Nursing Home is designed to meet the needs of older people living with or without dementia.

The service had a registered manager at the time of our inspection visit. 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 was not available during our inspection visit.

The first day of our inspection visit was unannounced. Ashfield Nursing Home was last inspected in May 2017 and was rated as Requires Improvement. We found breaches of Regulation 17 and Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider did not have effective systems to regularly assess and monitor the quality of care provided to people. Staff had not received training, support and supervision to enable them to carry out the duties they were employed to perform.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key question(s) Effective and Well-Led to at least Good. On this inspection, we found improvements had not been made. This is the second consecutive time the service has been rated Requires Improvement.

People were not always kept safe from the risk of acquiring infections. People’s medicines were not always managed safely. There was no comprehensive system to enable the provider to review accidents and incidents. There were times when there were not enough staff to meet people’s needs in a timely way. The provider had not taken steps to ensure the environment was suitable for people's needs. People were not given support to access community dental services, but were supported access other healthcare services when required.

People who needed support to communicate were not always able to meaningfully participate in making decisions about their care. People and relatives were not consistently supported to participate in planning or reviewing their care. The provider could not ensure that people, relatives and staff could meet in private, and there was a risk information about people’s care would not remain confidential. Concerns and complaints were not clearly resolved, and the provider did not have clear information about areas where improvements were needed.

The provider had not ensured their quality assurance system was effective in identifying issues and ensuring action was taken to improve the quality of care. The provider did not always respond to feedback from internal audits and external professionals to address areas where the quality of care was poor. The provider had not always notified CQC of significant events as they are legally required to do.

People were kept safe from the risk of abuse. The provider had ensured staff were of good character and were fit to carry out their work. Risks relating to people’s assessed needs had been assessed and mitigated. People received their personal and nursing care from staff who had training to enable them to meet people’s needs effectively. People were supported and encouraged to have a varied diet that gave them sufficient to eat and drink.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. The provider was working in accordance with the Mental Capacity Act 2005 (MCA), and people had their rights respected in this regard. People's right to private and family lives were respected. People and relatives were supported to discuss their end of life care, and staff knew how to support people and their relatives in the way they wanted.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Full information about CQC's regulatory response to these concerns found during inspection is added to reports after any representations and appeals have been concluded.

The provider is registered to provide accommodation for up to 40 older people living with or without dementia in the home over two floors. There were 35 people using the service at the time of our inspection. The home provides nursing care.

A registered manager was in post; however, they were no longer working at the service and had submitted an application to cancel their registration for the service. The service was being managed by two managers from other homes owned by the provider. Both managers were present on the first day of inspection and one of the managers was also present on the second day of the inspection. We were told that the new manager would be appointed shortly and they would apply to be registered for this service when in place. 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.

Safe medicines and infection control practices were not always followed by staff.

Staff knew how to keep people safe and understood their responsibility to protect people from the risk of abuse. Risks were managed so that people were protected from avoidable harm and not unnecessarily restricted. Sufficient staff were on duty to meet people’s needs and staff were recruited through safe recruitment practices.

Staff did not receive appropriate training and appraisal. Supervisions were not taking place for all staff. People’s needs were not fully met by the adaptation, design and decoration of the service.

People’s rights were protected under the Mental Capacity Act 2005. People received sufficient to eat and drink. External professionals were involved in people’s care as appropriate.

Staff were kind and knew people well. People and their relatives were involved in decisions about their care. However, advocacy information was not available to people.

People received care that respected their privacy and dignity and promoted their independence.

People received personalised care that was responsive to their needs. Care records contained information to support staff to meet people’s individual needs, though activities could be further improved so that more people could access activities outside the home.

Complaints were handled appropriately. A complaints process was in place and staff knew how to respond to complaints.

Systems were in place to monitor and improve the quality of the service provided, however, they were not fully effective. As a result the provider was not fully meeting their regulatory requirements.

People and their relatives were involved or had opportunities to be involved in the development of the service. However, actions did not always take place promptly in response to people’s comments.

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 this report.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, discussions with people who used the service, the staff supporting them and looking at records. We also spoke with the registered manager and the provider.

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

Is the service safe?

During the inspection we spoke with some people who used the service but most people were unable to share their views and experiences with us due to their communication difficulties. We therefore spent time in communal areas and observed how people were supported. We found that people were safe.

The registered manager told us how they had faced a number of challenges to ensure that people who used the service were supported by staff who had the right values and attitudes. The registered manager told us how they had taken action when staff were not suitable and we saw them take prompt action when they observed poor practice.

We saw that care plans were in place and had been reviewed to ensure that the support people who used the service received was appropriate to meet their personal care needs.

The registered manager was aware of their responsibilities in relation to referring allegations of abuse and poor practice to the local safeguarding hub (MASH) and to CQC. Recent incidents had been reported appropriately. Staff were confident that they could recognise signs of abuse and knew how and where to report allegations of abuse. Most staff we spoke with had received training in this area, although the training matrix supplied to us by the provider only reflected that one third of staff had completed this training formally.

The registered manager told us they were aware of the principles of Deprivation of Liberty Safeguards (DoLS), and told us how they had made referrals to check that people received appropriate support. We saw that assessments to demonstrate consent and capacity were, on some occasions, still required.

We asked the provider to tell us what they would do to meet the requirements of the law in relation to safeguarding vulnerable people.

We found a number of poor care practices in relation to the storage, recording and administration of medicines. We saw that some records of administration had not been signed as given. We saw the trolley containing medicines left open while the staff member took medicine to a person who was in their room. We also saw that appropriate checks were not taken after tablets had been administered covertly.

We asked the provider to tell us what they would do to meet the requirements of the law in relation to the safe administration of medication.

Is the service effective?

We spoke with one person who used the service. They told us, 'I like it here.' We saw how staff supported people. People's personal care needs were met in a timely manner, although we found people's social needs were not being effectively met at the time of our inspection. We saw staff interact with people as they did their jobs and spent time sitting with people. This interaction was however largely based around supporting them to eat and drink. The registered manager told us that they had appointed an activities coordinator and the provider said that there was money available to support activities. One staff member told us that a designated activities coordinator, "Will greatly improve people's quality of life.'

We saw that care plans and risk assessments were in place to support personal care tasks and there had been an improvement in the completion of daily charts. The manager told us they were monitoring this. This meant that staff could demonstrate that they had met people's needs.

We found systems for monitoring and assessing the quality of the service were in place however the provider did not have a system in place to record how they checked and reviewed the objectives they had set for the registered manager. Although the provider and the registered manager spoke regularly throughout the week there was nothing formally recorded about progress within the home and some objectives had not been met.

Staff told us that they felt well trained and well supported. We saw how training had been planned to ensure all mandatory courses were up to date, however the training provider had let them down. This meant that some staff had not been formally trained to meet individual support needs. The manager told us that they had to consider this when planning the rota and staff told us that they never had to do a task that they had not been trained to do.

Is the service caring?

Staff were kind and caring. Staff we spoke with told us about the people they supported and we found that staff were knowledgeable about people's individual needs and preferences. All of the staff we spoke with told us that they 'Loved' their jobs.

We saw that staff took their time to support people although at times they were more focussed on the tasks rather than meeting individual needs. For example, one person was asleep and staff left their meal in front of him rather than taking it away to keep warm.

We spoke with two relatives who were visiting the home. They told us, 'We can't fault them. They are wonderful.'

We asked the provider to tell us what they would do to meet the requirements of the law in relation to care and welfare.

Is the service responsive?

We saw how the registered manager had implemented systems and structures in response to previous issues within the home. For example, they told us how they had managed staffing issues to ensure that only people suitable to work with vulnerable people were employed at the home.

We saw how care plans and accident and incident forms were reviewed and care plans were updated and amended to reflect changing needs. We saw evidence that health and social care professionals were involved in reviewing and assessing people who used the service. This meant that staff could offer effective support as people's needs changed.

Is the service well-led?

We found that the registered manager had implemented a number of changes to ensure that the service was well led. They also told us that they had more to do to further improve the service. The provider confirmed that they had had discussions about planned changes. We recognised that staffing issues had impacted upon the registered manager's ability to 'manage' the service however they told us that they were now confident that a successful recruitment drive meant that improvements would now happen.

On the day of our inspection there were 17 people who lived at Kirkby Manor. Staff told us there were sufficient staff to meet their needs. They also told us they felt well supported by the registered manager.

The provider was proactive in supporting the registered manager as they regularly visited the service and discussed issues with them. There were however no records to show how the provider monitored and assessed the quality of the service and no records that they checked what the manager was monitoring. The provider told us that they did have such a system in place in their other services.

We undertook this inspection to check what improvements had been made since our last inspection in October and November 2013.

Since our last inspection there had been a reduction in the number of people using the service from 38 to 18 because admissions to the service were not taking place following the risks identified to people who used the service.

We found that the remaining 18 people who used the service were accommodated on the ground floor and the care they received ensured they were safe and their health was monitored appropriately.

We found that people who used the service received their medicines safely.

We found that there were sufficient staff employed with the right skills and experience to manage the needs of the people who used the service.

We found that the provider had employed a new manager who was in the process of registering with CQC. Staff told us they felt the home was now well led.

There were clear systems that had been put in place to monitor the quality of the service and ensure that it was effective and caring. The quality monitoring systems were supporting the provider to have a clear overview of how the service was being managed and inform them of any required action to ensure the service continued to sustain compliance with essential standards.

Care delivery supported people's privacy and dignity. Care planning ensured that all risks were identified and plans put in place to manage the individual needs of people who used the service.

We found that people who used the service did not always have their privacy and dignity respected and were not having their views and experiences taken into account in the way the care was being provided and delivered.

We found that people who used the service did not always experience effective, safe and appropriate care, treatment and support that met their needs or protected their rights.

We found that people who used the service were not always supported to have adequate nutrition and hydration.

We found that people who used the service were not always safe because their health and welfare needs were not met by sufficient numbers of appropriate staff.

The provider had not picked up on these issues and as such had failed to identify, assess and manage risks to people who lived at the service.

We found that the provider had continuously improved the service since our last inspection. A new manager with the right skills had been employed and was working hard to provide quality care. There were sufficient staff who were being supported to obtain skills and qualifications in adult social care and provide them with knowledge of how to support the specific needs of the people who used the service.

We spoke with three visitors to the home and asked them if they were happy with the care being provided to their relative, comments included, 'At first I thought that they would not be able to manage the needs of my relative due to the severity of the challenging behaviour. Now you would not recognise them as the same person, they are so much better and they told us that they liked the home and that staff look after them well. They have time to care here, she is well cared for and is always dressed in her own clothes.' Another commented, 'I would recommend this care home to my friends and relatives.'

We found that the required improvements had taken place and care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare and medicines were managed safely.

We were told by relatives and external health care providers that there was no consistency with the care that people received and staff did not always recognise when there were changes in the health and welfare of people who used the service.

Our evidence supported what people had told us. People who used the service were supported by an inconsistent and insufficient number of staff at Kirkby Manor that did not have the right competencies, knowledge, qualifications, skills and experience to meet their mental health needs.

We found that medicines were not managed safely and there was no effective monitoring of the quality of the service that people received. The provider did not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who used the service.

We found that care planning and care delivery did not always protect people from receiving unsafe care.

We found that there were sufficient staff available to support people safely but their dignity was not always maintained.

We found that the provider did not effectively monitor the quality of the service that people received and did not use the information in concerns to improve the quality of the service.