Ashton Lodge

Ashton Lodge is a residential care home providing personal care to 48 people most of whom were living with dementia and long-term conditions. The service can support up to 54 people.

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

One person said, “It suits me fine, staff are nice.” One person’s relative said, “Its so much better its improved a lot, they [staff] love her, they treat her like she is one of their own. Staff are very chatty; they talk to me as if they know me too.” Another person’s relative said, “I just wished I knew about this place when my parents needed to go into a care home.”

People’s safety was promoted at the home through staff and managers regularly monitoring and responding to changes in people’s health needs. Professional advice was sought quickly, and plans were made to ensure people were safe.

Care staff knew how to respond to any concerns to protect people from potential harm and abuse. The registered manager ensured checks were completed to ensure people were safe at the home, such as staff recruitment checks, equipment, building and fire safety checks.

There was a positive person-centred culture at the home. The registered manager, deputy manager and activity coordinators made efforts to promote people’s interests and to give people a happy and enjoyable experiences at the home.

Staff felt supported and listened to. The management team regularly audited and assessed the service to promote a good standard of care. Staff and relatives spoke openly about the improvements which had taken place over the recent years at the home.

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 12 March 2020). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last 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.

We carried out an unannounced comprehensive inspection of this service on 18 February 2020. A breach of a legal requirement was found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment.

We undertook this focused inspection to check they had followed their action plan and to confirm 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.

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 from requires improvement to good. 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 Ashton Lodge on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

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

We found there had been some key improvements since our inspections dating from April 2018. However, we did identify some shortfalls at this inspection. Mostly in medication administration and how pressure relieving equipment was being monitored. During our check of medicines, we identified issues with medicines records and the amounts of remaining medicines did not tally with what ought to have been given to people. People who were at risk of developing a breakdown to their skin did not have equipment set at the correct settings. There were still infection control risks from staff using the same sling when supporting people to be hoisted, rather than individuals having their own sling. The management team’s over view of these areas were not effective.

There were other safety checks in place to ensure the building and other equipment used was safe. The registered manager had sought advice from the fire service and actioned their recommendations to promote people’s safety in the potential event of a fire.

Staff were knowledgeable about what possible abuse could look like and they knew what to do about it. Staff were safely recruited. People had good risk assessments and care plans in place, which could direct staff about managing people’s needs. There were enough staff to meet people’s physical and emotional needs. We had some concerns raised by relatives about the length of the shifts staff worked. They felt some shifts were far too long which could affect staff practice.

We made a recommendation for the registered manager to seek guidance about how to monitor staff practice is effective when working these long hours and to take action about this.

The management team had identified people who were at risk of being an unhealthy weight. Processes were in place and action was taken to respond to these individual cases. People spoke well of the food. Staff responded when people needed support with eating and drinking. People were offered snacks and different drinks throughout the day. Efforts were made to make the dining experience a pleasurable one.

Staff felt supported by the management team. They were able to speak about how their training had helped them with their work. We saw examples of good staff practice in terms of supporting people to mobilise. Staff responded when people needed support and help.

When people were unwell and needed support from a health professional staff and the management team took action. The management team also liaised with other professionals to ensure people had the right support. This included people’s oral care.

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.

People and relatives spoke well of the staff, being kind and caring. Staff were polite and respectful to people. We did ask the registered manager to consider how people’s foot care could be managed in a way which fully promoted people’s privacy.

The management team had created good care assessments which highlighted people’s needs and preferences. People had been involved in the writing of these documents. These included plans for when people were dying.

We saw staff spending time with people and we were told about events which had happened and were being planned. However, we had seen some missed opportunities when people’s social needs were not being considered. Some people’s relatives also thought this area of people’s experiences could be improved upon. The registered manager needed to monitor and check if people’s social needs were routinely being met.

There was a friendly and positive culture at the home. Staff spoke about how they enjoyed their work and they felt at ease with approaching the management team. Progress was being made to involve the wider community into the home. Relatives said they felt welcomed and comfortable visiting their loved ones.

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 requires improvement (published 23 February 2019). The service remains requires improvement overall. This service has been rated requires improvement for two consecutive inspections. However, at this inspection key domains have improved to good.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified a breach in relation to the management of people’s medicines at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

We inspected Ashton Lodge in January 2019 and this inspection was unannounced. Ashton Lodge provides care for to up to 54 adults. Accommodation is provided over two floors.

Ashton Lodge 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.

We inspected Ashton Lodge in June 2016 and rated the home as ‘Requires Improvement’ overall. At the following inspection in September 2017 we rated the home as ‘Inadequate’ overall with breaches of the legal requirements. In April 2018 improvements had been made so the home was rated ‘Requires Improvement’ overall with Inadequate in well led.

At this inspection in January 2019 improvements had been made resulting in an overall rating of ‘Requires Improvement’ with Good in caring. At the previous inspection there had been three breaches of the legal requirements. In dignity and respect, person centred care and in the governance of the home. At this latest inspection there were no breaches of the legal requirements.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

There was a registered manager in place when we inspected the home. 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.

We found some issues which had the potential to put some people at risk of harm. A person’s oxygen was not being stored safely. The use and storage of the oxygen had not been risk assessed and was not being fully monitored to ensure the person using the oxygen and others were safe.

People who needed to be supported to be transferred using a hoist were at risk of becoming ill through cross contamination of the slings used in this process, as people did not have their own slings. We found staining on one of these slings and they were bunched together. We also found some recent errors with people’s medication. Some people had not received their medicines as prescribed. Some medicines were also not stored safely and some which were being used were out of date.

When we raised these issues with the registered manager they took swift action to start addressing them.

People had risk assessments in place and care plans to advise staff about how to meet people’s needs. However, we did find that improvements were needed in how the service managed and risk assessed people who were at risk of self-neglect. Systems and plans were not in place to manage these situations.

Staff recruitment checks helped ensure people were safe around new staff. However, staff did not have a full employment history in place despite this being brought to the provider’s attention at previous inspections.

Various safety checks were being completed of the equipment used and of the building to check people were safe. This included a recent fire safety inspection from the fire service.

Staff knowledge about what abuse could potentially look like was limited at times. Also, staff were not clear on how to report concerns outside of the home. We made a recommendation about improving staff knowledge in this area.

The management team completed various competency checks on staff when they started at the home and during their working life at the home. This was to ensure staff were performing well in their work and promote the knowledge of staff.

People were given enough to eat and drink. The service responded quickly when people were not eating enough and were losing weight. Some initiatives were in place to promote weight gain and sustain people’s weight who were at risk in this area. Records supported these actions. We did however suggest the service reviewed their approach to supporting people who were high in weight. People were not very critical of the food, but they were not very positive either.

People’s dining experience had improved, staff were more responsive to people in this way. People told us that they had choice with food. Although there were still areas where the service could promote people’s dining experiences.

Health professionals were contacted quickly when people became unwell or when there were signs they needed involvement from a health professional. One of these professionals spoke positively about the home and the actions of staff in keeping people healthy.

Staff offered people choices and understood the importance of supporting people to make decisions about the care they received. However, the management team’s knowledge needed to be improved upon when a deprivation of liberty was taking place and when to assess people’s capacity.

Staff were consistently caring, thoughtful, and considerate towards the people who lived at Ashton Lodge. People’s privacy and dignity was promoted. People appeared to enjoy the company of staff.

The management team captured people’s physical needs and interests in their assessments. Activities took place and events and trips had happened. Plans were being made for trips out for later this year. However, staff did not spend time chatting and engaging with people. Some people were left alone with limited stimulation for most of the day. Improvements had been made in this area, but further progress was still needed to promote people’s social experiences and their well-being at the home.

The issues found during the inspection reflected on the effectiveness of the management and provider audits taking place at the home. These issues had not been identified by audits undertaken by the provider and registered manager. However, some improvements had been made in this area. The provider now completed detailed audits of the service. The management team were completing more checks to assess people’s experiences of living at the home.

People spoke positively about the registered manager and the deputy manager. There was a positive culture at the home. Improvements were taking place and we had assurances that this would continue.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. 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.

Ashton Lodge 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.

Ashton Lodge provides personal care and accommodation for older people. Many people living at the home were living with some form of dementia. Ashton Lodge is registered to provide care for up to 54 adults. At the time of this inspection 51 people were living at the home. Ashton Lodge comprises of a building offering accommodation over two floors.

There was not a registered manager 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. There had not been a registered manager since 25 July 2017.

The previous provider’s nominated individual had taken over the management of the home following the last inspection. However, there were no provider level quality monitoring visits, to review the quality of the care being provided. The service had benefited from involvement from the local authority following the last inspection and rating of Inadequate. However, the service had no other plans in place to provide an independent review of the service. When this level of involvement provided by the local authority ends, it was unclear how the service will continue to develop. Especially without a registered manager in place.

Staff did not always treat people in a respectful way which promoted their dignity and wellbeing. Although improvements had been made in this area following our previous inspection staff were not consistently treating people in a respectful way.

Improvements had been made to promote people’s social needs. Activities were being provided daily. People who spent all their time in their rooms received some support and time from staff, although we questioned if these people needed or would benefit from more support from staff.

Despite this we found that the service was not always trying to meet people’s individual social needs. The management of the home was not always identifying people’s interests, past hobbies, and achievements. They were not using this knowledge in a meaningful way to actually promote people’s social needs. Staff were not spending time chatting and engaging with people on a regular basis.

These issues constituted a breach in the legal requirements. There were breaches of Regulation 17, 10, and 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These are continued breaches from the last inspection. You can see what action we told the provider to take at the back of the full version of the report.

People now had risk assessments in place which identified their needs and the risks they faced. However, these assessments did at times lack details about how people’s long term conditions were being managed and how they affected people on an individual basis. One person’s risk assessment had not been updated following a change to their needs. There was no new plan of action for staff to follow to help reduce the risks which they faced on a daily basis.

Infection control practices had improved which reduced the risk of spreading infection and potentially causing people to become unwell.

People received their medicines in a safe way. However it was not clear if people received their prescribed creams as the GP intended. Records of the administration of these products were not completed in full to demonstrate this.

Potential safeguarding concerns had been responded to appropriately by the manager at the home. Staff knowledge about how to protect people from experiencing harm and discrimination was not fully complete.

Various safety checks were completed to ensure the equipment used at the home was safe to use. Fire safety checks were being completed but it was unclear following a visit from the fire service if the home was fully legally compliant. The fire service had last visited the home in 2015. We suggested the manager revisited this safety issue.

The service’s emergency plan was not robust. It lacked some step by step practical information to guide the person in charge about what actions they should take in the event of certain emergencies.

Although staff practice had improved in key areas of their work, this was still an on-going process. Staff competency was now being reviewed and we saw staff practice being monitored when we visited the home. However, these competency checks were not well evidenced and did not demonstrate how the assessor had reached the conclusion that those individual members of staff were competent in areas of their work.

People were supported to have enough to eat and drink especially those who were at risk of being an unhealthy weight. These people’s food and fluid intake was being closely monitored and professional involvement was obtained and advice followed when this was appropriate. People were being given choices about what they ate and drank and people’s dining experience was being monitored. However, we still found that choice with food and drinks was not being fully promoted by the service. Improvements were also still required in people’s ‘meal experiences.’

People were being supported to make choices about the day to day care they received. Staff had a good knowledge about how to encourage people to make their own decisions. However, we found that ‘best interest’ processes when people potentially lacked capacity to make certain decisions, were not always being followed. This process is to support people to make decisions which they would have made if they did not lack capacity to do so.

We saw many examples of staff being kind and caring towards the people they supported. The management of the home had made changes to improve the culture and awareness of staff in meeting vulnerable people’s needs. However, work was still required in this area and we observed that some staff did not consistency treat people with respect or in a kind way.

Complaints were being processed in an open and transparent way. The management team sought people’s feedback and views on elements of their care and responded positively to this. However, further work was needed to fully review and consider if people’s individual needs were being met. Plans were being made to do this in the future.

The management team were monitoring how the care and support at the home was being provided. They were providing feedback to staff and reviewing their systems to try and ensure effective care was provided. They had identified the home’s values and were implementing these. Notable improvements had been made since our last inspection. Further time was required to see if the service developed further and to evidence if these changes are fully embedded into the service.

Ashton Lodge is registered to provide care to 54 people some of whom are living with dementia and long term conditions. The accommodation is set over two floors. Originally an old school, the building has been extended over the years.

There was not a registered manager 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The provider was considering applying to become the registered manager. We will be monitoring this. The provider was present at the home and working with the acting manager. Another manager from one of the providers other homes was also present, supporting the service.

At this inspection we found seven breaches of the Health and Social Care Act 2008. You can see what action we asked the provider to take at the end of this report.

The overall rating for this service is ‘Inadequate’ and the service is therefore 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 not enough improvement is made within this timeframe so that 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 so 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.

We brought the inspection forward due to a substantiated safeguarding concern.

People did not have robust and clear risk assessments in place which identified the risks which they faced, with a plan for staff to follow to mitigate these risks. The provider was aware of this issue and there was a plan to re-write these documents. However, this issue was raised at our last inspection and action to improve these documents had only just started.

The staff had a good understanding about how to protect people from potential abuse and harm. However, the existing management team did not have a full understanding about when certain safeguarding events, should be reported to the Local Authority and CQC.

We identified some concerns with potential infection control. Staff were not always following safe and appropriate practice to prevent the spread of infection. There were times when we identified hygiene issues in the communal bathrooms.

There were various safety checks which the service was completing in relation to ensuring the equipment within the home was safe to use. However, the service did not have an effective emergency plan in place for staff to follow, if there was an emergency within the building. Recruitment checks for staff were also not fully robust.

Documents and records were chaotic and often had information missing. Therefore we could not be confident that ‘accidents’, ‘incidents’ and people’s needs were always being responded to appropriately and in a timely way. The provider was aware of this issue, but there was no concrete robust plan in place at present to address this.

There were good levels of staff supporting people at the home. However, staff were not always effectively deployed, managed, and trained. Staff competency was not being routinely and robustly checked or monitored. Staff did not receive regular effective training in areas such as dementia care, or in conditions relevant to the people they were supporting.

Staff said they felt supported by the management team at the home and said they had regular supervisions and a good induction.

The Care Quality Commission (CQC) is required to monitor the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and reports on what we find. The service was working within the principles of the MCA. Staff had a good understanding about the need to seek consent from the people they were supporting.

People were not being supported to have choice with their food and drinks. People were not involved with the planning of what they ate and drank. Techniques to encourage people to make informed choices with their food were not being used. Staff sometimes rushed people they were supporting to eat. There was no regular review from the management of the home about people’s dining experiences and if people liked the food and drinks provided.

Staff were not consistently caring towards people. They did not always treat people in a kind and respectful way. Staff were sometimes short and direct with people. Staff did not always respond when people needed support. People’s confidential and sensitive information was not always protected.

People did not have personal care assessments, care plans and reviews which were relevant to them as individuals. People’s backgrounds and interests were not fully explored or identified by the service. The service did not try to match the social opportunities provided at the home to what people found interesting or enjoyed. There was a lack of social engagement from staff with people at the home; staff felt they did not have time to do this. There were no planned events or outings at the home. People did not engage with the activities provided. There was no attention or consideration given to look at ways to address this issue at the home.

The provider had not been completing audits or any thorough quality monitoring checks at the home. There was no current system to ensure this would take place in the future.

There were no robust systems in place to ensure people’s needs where regularly met. The management team were not completing routine quality monitoring checks. Systems to ensure accidents and incidents were addressed fully, were only just being developed. Improvements were being made to the service, but robust quality monitoring systems had not been put in place.

The staff spoke positively about the acting manager and the provider and had confidence in their leadership. The provider was working closely with the Local Authority to improve the service.

Prior to this inspection we had received concerns in relation to the infection control procedures in the service and the care people were receiving. We had also received concerns regarding the environment and the cleanliness of the kitchen.

Ashton Lodge provides accommodation and care for up to 54 people with a variety of social and physical needs, some of whom may be living with dementia. At the time of our inspection there were 40 people living at the service with one person having recently been admitted to hospital.

The service has a registered manager. 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.

An appropriate level of cleanliness was not maintained throughout the service.

People's needs had been assessed and care plans took account of their individual needs but lacked detail with regards to their preferences, choices and individuality. Care plans and risk assessments had been regularly reviewed to ensure that they were reflective of people's current care needs.

There were personalised risk assessments in place however they did not offer robust guidance to staff on how individual risks to people could be minimised and the care provided to some people was not consistent with the assessments in place.

There were mixed opinions with regards to the activities provided at the service. There were limited activities on the day of our inspection and some staff we observed did not engage people in social conversation.

People told us there were sufficient numbers of staff on duty. However we observed there were significant periods of time when people were not supported by having a member of staff available. This was mainly observed during early morning, within the communal lounge areas of the service.

The registered manager completed quality monitoring audits and it was clear how these were used to drive improvements in the service however they did not routinely consider the experiences of people living in the service.

Staff understood their responsibilities with regards to safeguarding people and they had received effective training. Referrals to the local authority safeguarding team had been made appropriately when concerns had been raised.

Medicines were managed safely and medicines audits were completed regularly.

Safe recruitment processes were in place and had been followed to ensure that staff were suitable for the role they had been appointed to prior to commencing work.

Staff were trained and had the skills and knowledge to provide the care and support required by people. New members of staff received an induction.

People’s consent was gained before any care was provided and the requirements of the Mental Capacity Act 2005 and associated Deprivation of Liberty Safeguards were met.

People were supported to make choices in relation to their food and drink and a varied menu was offered. People's health care needs were being met and they received support from health and medical professionals when required.

Staff were friendly and respectful. People's privacy and dignity was promoted throughout their care. People were provided with information regarding the services available.

The management team were approachable and staff felt supported in their roles.

People and staff knew who to raise concerns with and there was clear line of accountability amongst senior staff.

We observed people were engaged in an armchair exercise by an outside facilitator which they enjoyed. Interactions between people and staff were positive. We found that staff treated people with respect and upheld their dignity. For example, staff called people by their preferred name. When providing assistance to people they made sure that they explained what they were about to do.

We found that people looked comfortable in the company of staff and there was a relaxed atmosphere in the home.

The system in place to maintain appropriate standards of cleanliness and hygiene in the home had been reviewed to ensure that people lived in a clean hygienic environment.

We found that risk assessments to identify any potential risks of the premises being unsafe or unsuitable had been undertaken to ensure people who use the service, staff and visitors were protected against the risks of unsafe or unsuitable premises.

The complaints process had been reviewed to ensure that the complaints system was effective and complaints were investigated within the agreed timescale and to people's satisfaction.

We found that people were satisfied with the care and support they received. They said staff respected their privacy and dignity. Everyone said the care provided was good. One person said, 'They (Staff) have a hard job here and they do a great job'.they do keep me comfortable.' Another person said, 'I have nothing I could complaint about, I am very well cared for.'

We found that appropriate standards of cleanliness and hygiene in the home were not maintained. People were not protected against the risks associated with unsafe or unsuitable premises. An effective complaints system was not in place to ensure that complaints made were fully investigated and so far as reasonable practicable, resolved satisfactorily.