Archived: Ashley House

Ashley House is a residential care home providing personal and nursing care to 14 people aged 65 and over at the time of the inspection. The service can support up to 17 people in one adapted building.

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

Very few improvements had been made since the last inspection. There continued to be shortfalls in the service provided to people.

Risks to people in relation to fire safety and evacuation had not improved since the last inspection. Other environmental risks were evident and had not been recognised. Some people’s individual risk assessments had improved. Some areas, however, had been missed so care may not be sufficient to meet their needs.

People could not be assured their prescribed medicines were safely managed as monitoring measures were not sufficient to ensure safety. Although infection control procedures were in place, these were not robust enough to assure people they were being kept safe.

Although staff knew people well and knew what support they needed, their care was not always person-centred, taking account of their privacy and rights.

The provider had limited oversight of the service and had not planned to make the improvements needed since the last inspection. People could not be assured the service was going to make the necessary changes to ensure the quality and safety of their service.

Enough staff were available to make sure people received the support they needed. Some changes needed to be made to the management processes to assess the numbers of staff required. Staff employed to make sure people received safe care and support were checked by the registered manager, although some areas needed to be improved.

People were kept safe from abuse, the registered manager reported concerns and staff knew how to raise concerns and who with.

People had the opportunity to be involved in giving their views and being involved. They were supported by staff who were listened to and enjoyed their work.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 8 January 2020) and there were multiple breaches of regulation. The service remains rated requires improvement. The service has been rated requires improvement for the last four consecutive inspections.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection. We carried out an unannounced comprehensive inspection of this service on 3 October 2019. Breaches of legal requirements were found. We took enforcement action against the provider and registered manager. We served a warning notice, requiring them to be compliant with Regulation 17 by 28 February 2020.

We undertook this focused inspection to check the provider and registered manager had made improvements and to check they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements. We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from the previous comprehensive inspection for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service remains requires improvement overall. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Ashley House on our website at www.cqc.org.uk.

Enforcement

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 breaches in relation to Regulations 12 and 17 at this inspection.

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.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The overall rating for this service is ‘Requires improvement’. However, we are placing the service in 'special measures'. We do this when services have been rated as 'Inadequate' in any Key Question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in special measures. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement 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. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.

Ashley House is a residential care home providing personal and nursing care to 15 people aged 65 and over at the time of the inspection. The service can support up to 17 people in one adapted building. People had varying care needs, including, living with dementia, recovering from a stroke and diabetes. Some people could walk around independently, and other people needed the assistance of staff or staff and equipment to help them to move around.

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

Enough improvement had not been made since the last inspection to evidence a good service was being provided.

Safety measures to reduce risks had improved. However, changes in people’s needs had not been reflected in the records kept, so people could not be assured the care provided was sufficient to safely meet their needs. Risks around the environment were not always kept up to date to keep people safe and accidents and incidents were not closely monitored to prevent a reoccurrence.

Suitable references were not always received for new staff. Some areas around the premises were not maintained appropriately to make sure people were not at risk of the spread of infection. We have made a recommendation about each of these areas to encourage improvement.

New staff did not complete essential training in a timely manner to make sure they had the knowledge to provide good support and keep people safe. The premises were not maintained to a suitable standard to provide a comfortable living area and to make sure people had the facilities to protect their privacy.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. However, records kept did not always reflect this practice. We have made a recommendation about this.

Although the provider had started to make changes to provide a more dementia friendly environment, we found this was still an area for improvement.

Although staff knew people well and knew what their likes, dislikes and preferences were, the records kept did not always reflect changes in people’s needs. There was a lack of opportunities for people to follow their interests and hobbies to provide stimulation and promote their well-being.

Information for people was not provided in accessible formats so people who had difficulty reading words and sentences could understand them. The provider had started to make changes. We have made a recommendation about this.

When people raised a verbal concern or complaint, these were not logged so the themes could be checked, and lessons learnt. This is an area we found needed to improve.

The management and oversight of the service was not robust enough to identify areas of concern and put actions in place to continuously improve quality and safety. This was the fourth inspection where the provider and registered manager had not achieved a rating of good.

People and their relatives felt safe and said they were well looked after. People could be assured their prescribed medicines were administered safely.

People had good choices at mealtimes and their varying diets were known and understood by kitchen and care staff. People were supported to access health care when they needed it and were supported to attend appointments if needed.

There was a good atmosphere in the service where people chatted with staff and had a joke. Staff were happy in their work which helped to create a comfortable environment for people. People’s privacy and dignity was respected, and they were supported to maintain their independence, which supported their well-being.

People, staff and relatives found the registered manager approachable and said they made time for everyone. People had the opportunity to share their views and this was supported by the views of relatives and external agencies. Staff were supported through staff meetings and one to one supervision meetings to make sure they were fulfilling their role in supporting people in the way they wanted.

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

Rating at last inspection and update

The last rating for this service was Requires Improvement (report published 4 October 2018). At this inspection, enough improvement had not been made and the provider was still in breach of regulations. The service remains rated requires improvement. This service has been rated requires improvement for the last four consecutive inspections.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

At this inspection, we identified two breaches that had continued since the last inspection in relation to, risk management, accurate record keeping and quality monitoring, and three further breaches in relation to, maintaining suitable premises, new staff induction and training, and meeting people’s needs and preferences.

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.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Ashley House is a ‘care home’. People in care homes receive accommodation and nursing and personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Ashley House provides accommodation and support for up to 17 older people living with dementia. There were 15 people living at the service at the time of our inspection.

There was a registered manager in post who was present on both days of inspection. 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.

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 responsive and well led domains to at least good. Our last inspection on 18 May 2017 found one breach of our regulations and an overall rating of requires improvement was given at that inspection. This was because records were not being maintained to provide an accurate contemporaneous record. Information in people’s care plans detailing their care and support needs was not always current to inform and guide staff. Audits of the service were undertaken but were not effective in highlighting shortfalls and were an area for improvement. The provider sent us an action plan after this inspection telling us how they would improve and when this work would be done.

Improvements had not been embedded or sustained and the original breach has subsequently not been met. Person centred care plans were still not always reflective of current care and support needs. We found that further shortfalls in relation to the governance of the service had occurred, some risks had not been identified and addressed to keep people safe and there were several areas for improvement. The previous ratings for the key questions safe and effective had not been sustained. The overall rating for the service remains at requires improvement. This is the third consecutive time the service has been rated requires improvement.

We found that some risks were not identified and therefore measures not implemented to protect people from harm. We observed a missing window restrictor on a first floor window, loose stair carpet and unsafe storage of oxygen. These shortfalls could place people at risk of harm. The system of audits and checks in place to monitor service quality did not always identify the shortfalls as intended and other shortfalls were not considered at all. For example, there was no system for monitoring air mattress settings to protect people’s skin integrity and no clear responsibility for cleaning the medicine room to maintain good infection control. Safety recommendations from equipment servicing was not included in the maintenance plan. Recommendations from pharmacy audits were not actioned. This meant there was a risk that some shortfalls were being overlooked and could impact on the operation of equipment or pose a risk to people or staff. The provider had not ensured that staff were working to the most up to date policies.

Not all aspects of cleanliness and infection control were monitored. An absence of a robust cleaning and monitoring schedule meant some areas of the service were not sufficiently clean. Equipment was serviced at regular intervals to ensure it remained in working order.

A complaints procedure was displayed for people to use if they wished. However, accessible information about the service including the complaints procedure was not in formats suited to the needs of those with dementia or cognitive problems and is an area for improvement. People and relatives told us that they knew how to complain if they needed to.

There were sufficient staff on duty to meet people’s needs. Staff were provided with a wide range of training in topics relevant to their role and the needs of the people in the service, this was kept updated, but staff induction needed better recording.

The majority of environmental and individual risks to people had been assessed and measures implemented to reduce the risk of harm occurring. Fire safety equipment was checked and tested; staff attended fire drills to remind them of the actions to take in an emergency. Individual evacuation plans had been developed for people to inform staff the level of support each person required to leave the building safely. A business continuity plan was in place to ensure people continued to receive a safe level of support if emergencies occurred that affected the running of the service.

Staff showed that they knew people well and understood the things that were important to them. Staff knew how to recognise signs of abuse and how to report and escalate their concerns so people were protected Accidents and incidents were appropriately reported, recorded and actions taken to ensure people received the support they needed.

People were supported to have maximum choice and control of their lives and staff support them in the least restrictive way possible, the policies and procedures and systems in the service support this. New people to the service were assessed to ensure needs could be met and any protected characteristics under the Equality Act 2010 recorded to ensure these could be supported. Staff received training in Equality and Diversity to inform their support of people.

People’s individual healthcare needs were assessed and monitored to ensure they remained well. Medicines were appropriately managed and people received them when needed. People’s end of life choices and decisions were recorded where known, so staff understood how people wished this to be managed.

People enjoyed their meals and were given choices. Specialist diets were catered for. Risks of malnutrition and dehydration were assessed and measures implemented to reduce the likelihood of this occurring.

People were supported to maintain their independence and do as much for themselves as possible. Bedrooms were personalised and people's preferences were respected. Staff respected people’s privacy and dignity and supported people with kindness, respect and patience. Relatives were made welcome and visiting was flexible.

People were provided with a varied range of activities when resources allowed promoting their interest and stimulation.

People and relatives were surveyed for their views. People’s survey feedback was analysed but actions taken and survey results were not shared with people and relatives and this is an area for improvement.

Staff said they enjoyed working at the service, they found the registered manager approachable and thought that team work and communication was good. Staff were provided with regular staff meetings and said they felt able to express their views and felt listened to.

We have made a recommendation in respect of accessible information including complaints.

We have made a recommendation for improved activity provision for people with dementia.

During this inspection we found three breaches of the Health and Social Care Act 2008 regulations. You can see what action we told the provider to take at the back of the full version of the report.

Ashley House is registered to provide personal care and accommodation for up to 17 people. There were 16 people using the service during our inspection; who were living with a range of health and support needs. Many people were living with different types and stages of dementia. Ashley House is a detached house situated in a residential area in Folkestone, with access to the town centre. There were 16 bedrooms, one being able to offer double occupancy. People’s bedrooms were provided over three floors, with a passenger lift in-between. There were sitting and dining rooms on the ground floor and an enclosed garden to the rear.

The service had a registered manager, who was present throughout the inspection. 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 and associated Regulations about how the service is run.

The care and support needs of each person were different, and each person’s care plan was personal to them. People had care plans, risk assessments and guidance in place to help staff to support them in an individual way. However, information and guidance contained within care records was not always the most recent.

A number of audits and checks were carried out each month by the registered manager or area manager, but they had not been effective in identifying the shortfalls in current information within care plans highlighted during our inspection.

There were enough staff on duty and they had received relevant training and supervision to help them carry out their roles effectively. Staff were observed putting their training into practice in a safe way. There was no use of a formal dependency tool to enable to registered manager to assure themselves that staffing levels remained adequate. Recruitment files contained all the required information about staff.

Staff knew how to keep people safe from abuse and neglect and the manager referred any incidents to the local safeguarding authority as appropriate. Incidents and accidents had been properly recorded and preventative actions taken. Fire safety had been addressed through training, drills and alarm testing. Maintenance had been carried out promptly when repairs were needed.

Medicines were managed safely. People received their medicines safely and when they needed them. People were supported to maintain good health and attended appointments and check-ups. Health needs were kept under review and appropriate referrals were made when required.

Staff encouraged people to be involved and feel included. There were positive and caring interactions between the staff and people and people were comfortable and at ease with the staff. People's privacy and dignity was respected.

Staff treated people with kindness, compassion and respect. Staff took time to speak with the people they were supporting. We saw many positive interactions and people enjoyed talking to the staff. The staff on duty knew the people they were supporting and the choices they had made about their care and their lives.

Activities were offered to people; with a range of one to one and group activities to meet individual needs and preferences.

Complaints had been properly documented, and recorded whether complainants were satisfied with the responses given. People and relatives said they knew how to complain if necessary and that the registered manager was approachable.

People had a choice of meals, snacks and drinks, and could choose where they would like to eat. Staff encouraged people to eat their meals and gave assistance to those that required it.

Staff understood the principles of the Mental Capacity Act and knew how to support people who were not able to make their own decisions. People's rights were protected.

Staff reported that they were clear about their roles and felt well supported by the registered manager and the unit managers for each floor. Staff said there was good communication. Feedback was sought from people, relatives and professionals.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have asked the provider to take at the end of this report.

Ashley House provides accommodation with personal care for up to 17 older people living with dementia. There are 15 single and one double room available. There were 15 people living at the service at the time of inspection and everyone was living in a single room. The accommodation is over two floors and bedrooms can be accessed by a passenger lift. There is a communal lounge at the back of the home with access to a secure garden. There is also a separate dining room where most people eat their meals.

The service has a registered manager who was available and supported us during the inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

Medicines controlled under the Misuse of Drugs Act 1971 to prevent them from being misused and causing harm, were not stored securely at the service. There were no protocols in place for people who were prescribed their medicines to be given ‘as required’. There was no guidance in place for staff to follow to maintain the health of people with diabetes.

The hall and stair carpet was worn, had a number of small holes and a patch by the dining room door, which posed a tripping hazard. The provider was aware of the hazard, but had taken no action to address it to make the environment safe.

Each person had an individual plan in place detailing how to evacuate them in the event of a fire. However, the equipment needed to evacuate one person safely, was not available at the service.

Around half the staff team had not received training in areas essential to their role, including safeguarding, health and safety, fire prevention, infection control, moving and handling people safely and The Mental Capacity Act 2005 (MCA). The service specialised in supporting people living with dementia but care staff had only received basic training in this area and had received no training in how to effectively support people with behaviours that may challenge themselves or others. There was no plan in place which identified when these training gaps would be met.

There was not an effective quality assurance process in place and the provider did not respond to shortfalls identified in the service in a timely manner.

People had their health needs assessed and monitored and professional advice was sought as appropriate. People were offered a choice at mealtimes, and where appropriate support was provided and people were not rushed.

CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards. The registered manager had consulted the local authority with regards to making DoLS applications, so people were not deprived of their liberty unnecessarily.

Staff said there was good communication in the staff team, that they felt well supported and received regular formal supervision with the registered manager.

Checks were carried out on all staff to ensure that they were fit and suitable for their role. Staffing levels ensured that staff were available to meet people’s needs. Staff knew how to follow the home’s safeguarding policy in order to help people keep safe.

The home was clean and staff knew what action to take to minimise the spread of any infection.

People, visitors and professionals gave positive feedback about the compassionate and caring nature of the staff team. Staff were kind and caring and communicated with people appropriately using touch. Staff valued people, showed concern for their well-being and involved them in decisions about their care.

People’s care, treatment and support needs were assessed before they moved to the service and a plan of care developed to guide staff on how to support people’s individual needs. Information had been gained about people’s likes, and past history and staff had a thorough understanding of people’s choices and preferences.

People and visitors knew how to raise a concern or complaint, but said they had not needed to do so.

The registered manager was passionate about providing a personalised service for people and led by example. Quality assurance feedback was sought from people, relatives and professionals.

We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.

We considered our inspection findings to answer 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, speaking with relatives and speaking with staff.

Is the service safe?

People were treated with dignity and respect by the staff. They knew how to communicate with individual people who lived in the home and did so in a way that valued their contributions. One relative told us, 'The staff are lovely. It is like a big family'. Another relative told us, 'Mum is well looked after. They let us know what is going on. I do not worry when I leave Mum'.

There were systems in place to ensure that the environment was clean and hygienic. Staff understood their roles and responsibilities in ensuring that the home was clean and had received training in how to minimise any infection.

Checks had been carried out for staff before they started work at the home, to ensure that they were suitable for their roles.

Systems were in place to monitor accidents and incidents. This reduced the risks to people and helped the service to continually improve.

Is the service effective?

Relatives were very positive about the care that was delivered and said that their relatives' needs were met.

People's health and care needs were assessed with them, and they and/or their relatives were involved in writing their plans of care. This included important information about people's likes, dislikes and past histories, so that staff could communicate with people more easily.

Staff had a good understanding of people's care and support needs and they knew them well. We observed staff communicating with people about things that were important to them.

Is the service caring?

People were supported by kind and attentive staff. For example, we saw staff sitting down beside people when talking with them and supporting them to eat and drink. Staff showed patience and gave encouragement when supporting people. When supporting people to mobilise, they explained and involved the person in every step of the process.

People were able to do things at their own pace and were not rushed. We saw that there was a relaxed atmosphere at lunchtime and that meal times were staggered so that people could be provided with the individual support that they required

People's preferences, interests and diverse needs were recorded and care and support was provided in accordance with their wishes.

People using the service, their relatives, staff and other professionals involved in the service completed an annual satisfaction survey. Any shortfalls had been identified and action had been taken to address them.

When speaking with staff it was clear that they genuinely cared for the people they supported.

Is the service responsive?

People's needs had been assessed in detail before they moved into the home.

People had a designated key worker and protocols were in place setting out their roles and responsibilities

People had access to activities that were important to them, in the home. An activities coordinator was employed two afternoons a week. Staff said that they had time to sit and talk to people and showed us some of the activities that they engaged people in such as picture bingo.

People had been supported to maintain relationships with their friends and relatives.

Relatives said that they knew how to make a complaint if they were unhappy, but said that they had not needed to.

Is the service well led?

The home manager had worked at the home for many years, was registered with the Care Quality Commission and had achieved a national qualification to manage a social care service.

Staff had a good understanding of the ethos of the home. They told us that they were clear about their roles and responsibilities, felt well supported, and that there was good communication in the home. All these things helped them to provide the appropriate support for people who lived in the home.

The service had an effective quality assurance system in place which consisted of internal audits and external audits by the provider.

Relatives, staff, people who used the service and professionals completed an annual customer satisfaction survey. The results were analysed by the provider so that any shortfalls could be addressed.

We spoke to people and their relatives, who told us that they were happy with the care and support the home provided. One person told us 'staff are very good; they work hard and communicate well with people'. A relative told us 'I wouldn't hesitate to recommend the home to other people'.

We found that care plans were individualised and contained people's choices and preferences and that people's health care needs were met. A relative told us 'the staff respond well to people's needs'.

We found that the home had arrangements in place to protect people from the risk of abuse and people told us that they felt safe.

We found that the home had appropriate arrangements in place to manage people's medicines and staff had received training to administer medicines safely.

We found that staff were supported by the provider to effectively meet the needs of people who lived in the home. One person told us 'they are well trained to look after individuals'. A member of staff said 'they are the best manager I've ever had'.

A healthcare professional linked to the service told us 'It is one of the best homes I have been in, the staff are well trained and caring."

We saw that there were systems in place to monitor people's capacity to give consent and ensure decisions were made in their best interests.

We saw that people had their needs assessed, met and reviewed at the service. However, we noted an example where a lack of guidance for staff around responding to a person's behaviour meant a staff member's response caused the person some distress. The manager amended the guidance during the inspection.

People told us that the staff were able to meet their needs and there were enough staff on duty to meet their needs effectively.

We saw that the environment was homely and regular health and safety checks were undertaken of the service. There was a system in place to maintain the service including redecorating areas that had become worn.

There was a complaints system in place and information for staff, relatives and people around how to make a complaint. No complaints had been made.