The inspection of Ashleigh Manor Residential Care Home (“Ashleigh Manor”) took place on the 15 and 16 May 2018 and was unannounced. We carried out this inspection as a responsive comprehensive inspection due to concerns we had shared with us about the service. This included information from whistle blowers and following a review of our records in line with our intelligence monitoring. Details of how we monitor Adult Social Care Services that are registered with us can be found on our website at: http://www.cqc.org.uk/guidance-providers/adult-social-care/how-we-monitor-inspect-adult-social-care-servicesOur information raised concerns about the number of falls resulting in injury, medicine errors, how people’s continence care was being managed and moving and handling practices.
We were told there was not enough staff or the right equipment to meet people’s needs. Also, people’s medicines were not being fully signed for, people were not having their prescribed creams put on their skin and people’s continence needs were not being met. Staff were also not reading care plans so were unaware of people’s needs and preferences.
In addition, there were concerns about staff were not speaking to people, staff not wearing gloves and aprons as they should and staff were not passing concerns on to management and complaints were not being dealt with appropriately.
When we completed our previous inspection on 27 and 28 September 2017 we found concerns relating to staffing levels; gaps in medicine records; people’s care plans not fully reflecting their care; activities not being personalised and the provider was not ensuring the quality of the service. This meant we rated the key questions of Safe, Responsive and Well-led as Requires improvement. Effective and Caring key questions were rated as Good.
We requested the provider to tell us in an action plan how they were going to put right the concerns in respect of breaches of Regulations for staffing the service safely; assessing, monitoring and improving the quality of the service and in ensuring people’s records were complete and accurate.
Ashleigh Manor 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.
Ashleigh Manor can accommodate 65 people in two separate parts of the premises. These are known as ‘The Manor’ and ‘The Lodge’. Historically, people in The Manor are living with dementia or complex needs and people of reduced complexity lived in The Lodge. However, on this inspection we found people had complex needs in both parts. When we inspected, there were 51 people living at the service. The Manor had 25 people living there and 26 in The Lodge.
A registered manager was not currently in place in respect of this service. However, the current manager was in the process of registering with us. 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. They were supported in running the service by a care manager, two administrators and one of the registered partners/provider. One of the provider’s daughters acted on behalf of the registered provider during the inspection with the main partner/provider attending the second day of the inspection.
On this inspection, we reviewed the concerns we had received and checked to see if the provider was compliant following the last inspection. We found some improvements had been made in some areas but we also found continued concerns and some new concerns that are summarised below.
Staff described the lack of staff and equipment as the two main issues impacting on people.
Robust quality assurance processes were not operating. Audits of parts of the service were not in place or being reflected on to ensure all areas of the service were operating safely, effectively, caringly or responsively.
Staff told us they felt unsafe speaking out about how they were feeling as “it got round” if you spoke out. We advised the provider of this, who met with the staff to seek their concerns and issues.
The service was not staffed safely to meet people’s needs. The service was also not staffed in line with the stated provider’s minimum staffing levels. Also, staff from the Lodge were being repeatedly moved to fill gaps in staffing the Manor. As a result people’s basic care needs were not being met; people were not always having their hydration needs met, people did not always have choice and the quality of their care was compromised. On the second day of the inspection, the emergency call bell was sounding repeatedly for long periods as staff were unable to respond in the expected time to meet people’s requests. Only care staff were expected to respond to these bells; team leaders and management were not. This meant an air of complacency had developed in respect of the risk to people.
The service also did not have the required equipment to meet people’s needs in a timely way. There were two hoists and one stand aid, without the required sole use sling, which meant people had to wait for equipment to become available. The only wet rooms that were accessible by a wheelchair and two staff were found in the Manor. People from the Lodge were less likely to have their chosen shower routine at a time they wished and when this did take place, people were rushed due to availability of enough staff. We found that staff were not always using slide sheets for people who required help with moving and handling. These are used to move people in bed while reducing the friction on the skin.
Staff were observed being kind and compassionate to people throughout the inspection, but their ability to have quality time with people was being compromised by all the tasks they needed to complete.
Demands on staff time meant that staff were not reading people’s care plans and risk assessments. Care staff relied on the team leader to tell them informally and verbal information from other staff. Although care plan records had improved since the last inspection, essential details were still missing from these and the risk assessments which meant the team leaders could not be sure they were using up to date information about people’s current needs. Care records were not fully completed which meant people’s changing needs could be missed. Monitoring of people’s eating, fluid intake and out puts (such as urine and bowels) were inconsistently being recorded. This meant people were vulnerable to unsafe and inaccurate care.
People’s oral medicines were recorded and the systems around this had improved since the last inspection. However, those in relation to people’s prescribed creams had not. Staff were not recording when they had been used, opened, needed disposing or making sure new creams were available. Where body maps were in place to help staff know what topical medicine to use they did not include when and not all creams were represented.
Staff were not being trained to effectively carry out their role. Staff training in many key areas had lapsed or had not been completed at all. Staff were relying on being told by other staff what was the right way to do things. Supervisions and staff competency assessments (except around medicines) had recently been reintroduced. People’s capacity to consent to their care was considered, however staff had not always had the training to understand how this applied to their role. This was again placing people at risk of unsafe care.
People’s experience of care was also affected by the level of stimulation and activity available, which varied in The Manor and The Lodge. People living in the Manor tended to experience a higher level of stimulation than those living in the Lodge.
However, the chef interacted with people and, along with the kitchen staff generally, was highly regarded by people, staff and relatives. People were very positive of the food and grateful for the lengths the kitchen staff went to ensure they had what they liked to eat.
Some areas of fire safety and maintenance of the building required improvement. The fire service had visited and given verbal advice. We were told new systems of overseeing maintenance and fire safety had been introduced recently followed by a gap in ensuring these were monitored.
We found little evidence of compliance with the Accessible Information Standards and how the service was ensuring people’s Equality, Diversity and Human Rights Needs were being incorporated into their care. The Accessible Information Standard applies to people using the service (and where appropriate carers and parents) who have information or communication needs relating to a disability, impairment or sensory loss. However, people could have access to professional advocates to speak on their behalf if needed. A signer was provided for one person who was deaf and used sign language when having health meetings; but staff did not following advice from to maintain a good face to face position so the person could lip read.
People were protected from infection cross contamination due to clear processes and practices being in place. However, not all staff had received training in infection control. People, and their families, were positive about being able to approach staff at any time to talk about their care. People’s complaints were looked at in detail and action taken to put things right.
People’s health needs were met and they could see a range of health and social care professionals as needed. The visiting nurse we spoke with was happy the service would call them if needed.
We found breaches of the regulations. We are considering o