The Aylsham Manor

The Aylsham Manor is a residential care home providing accommodation and personal care to up to 30 people. The service provides support to older people some of whom may be living with dementia. At the time of our inspection there were 27 people using the service.

The home provides accommodation over 2 floors of a converted period building. There are multiple communal areas and extensive gardens and the home is close to local amenities.

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

The provider had made significant improvements across the service since our last inspection. However, further embedding and additional progress was required. For example, the governance systems in place had not wholly identified and rectified some issues such as gaps in recruitment practices and training and the need for better records in relation to the Mental Capacity Act 2005 (MCA).

People told us the service had a positive impact on their lives and their relatives agreed. People told us they were happier, more confident and felt a sense of belonging living at The Aylsham Manor. Relatives told us the home provided them with peace of mind, confidence in the staff and the knowledge their family members were well cared for. People told us they would recommend the service.

We saw that 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, associated records did not always consistently demonstrate this, so the provider needs to ensure this is achieved.

Staff demonstrated the appropriate skills and knowledge to support people in an individualised, respectful and compassionate manner; people told us this and our observations confirmed it. However, there were some gaps in training and the provider needs to ensure this is rectified.

People felt safe living at the service and the associated processes in place helped to achieve this. For example, people received their medicines as prescribed and risks had been identified, managed and mitigated. Improvements had been made in relation to safeguarding practices and we saw the provider was engaging with other professionals appropriately and as required.

People’s needs had been assessed holistically and met on an individual basis. They, their relatives and staff were involved in the service and felt supported and listened to; communication was good. Improvements had been made in recording and analysing accidents and incidents and in the use of reflective practice to further improve the service and reduce future risk.

The culture of the home was positive, nurturing and welcoming. People told us this and our observations confirmed it. Staff felt valued and supported and the people who used the service told us their lives were led happily and with quality.

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 October 2022) and there were breaches of regulation. 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. However, the service remains rated requires improvement. This service has either been rated requires improvement or inadequate for the last 5 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 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 will continue to monitor information we receive about the service, which will help inform when we next inspect.

The Aylsham Manor is a residential care home providing care and support to up to 29 people aged 65 years and over, some of whom were living with dementia. At the time of our inspection there were 26 people using the service. The service consisted of an extended main house with bedrooms across two floors, and communal facilities, with accessible outside space.

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

We continued to find concerns in relation to the management and oversight of incidents involving people and found multiple examples of where safeguarding referrals had been made to the local authority, but no notification had been made to CQC in line with the provider’s regulatory responsibilities. We reviewed people’s dependency needs, against staffing levels, and identified there were not sufficient numbers of staff on shift at night time. This was of particular concern in the event of needing to support people to evacuate the building in an emergency such as a fire. We also identified an example of poor risk management in relation to pre-employment checks, and management of known risks which did not ensure the protection of people living at the service; resulting in ongoing breaches of the regulations.

Overall standards of care, and the systems required to support care delivery had improved since the last inspection. People consistently gave positive feedback about the care they received, including the choice of meals, flexibility in timing of when they got up or went to bed. We received positive feedback in relation to people’s levels of individual and group activity involvement within the service, as well as enjoying the option of accessing the local community.

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, we continued to identify the assessment of people’s mental capacity to be of poor quality, resulting in an ongoing breach of the regulations.

Improvements had been made in the monitoring of risks, within their care and support needs and the wider care environment, to maintain people’s safety and well-being. People’s care records were an accurate reflection of their day to day needs and were regularly reviewed following incidents and accidents such as falls. People received their medicines on time, from staff trained to safely support them, with timely access to medical input if their needs were felt to have changed.

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 Inadequate with breaches of the regulations, (published 29 November 2021).

At this inspection we found some improvements had been made, however the provider remained in breach of the regulations.

At our last inspection we recommended for the use of recognised risk assessment forms, to ensure all relevant checks were recorded and risk mitigation in place, as part of the pre-employment process. At this inspection we found the provider had not acted on this recommendation, which resulted in a breach of the regulations.

This service has been in Special Measures since 21 July 2021. During this inspection the provider demonstrated some improvements have been made. The service is no longer rated as inadequate overall but is in the key question of well-led. Therefore, this service remains in Special Measures.

Why we inspected

As an outcome of the last inspection, due to continued breaches of regulation and remaining in special measures, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Aylsham Manor on our website at www.cqc.org.uk

The overall rating for the service has changed from inadequate to requires improvement, based on the findings of this inspection. We have found evidence the provider continues to need to make improvements. Please see the safe, effective and well-led sections of this full report.

Enforcement and Recommendations

We have identified ongoing breaches in relation to governance and oversight of the service, staffing, consent and capacity, and protecting people from risk of harm or abuse. We have also identified a new breach of regulation in relation to recruitment processes. 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 continue to monitor information we receive about the service, which will help inform when we next inspect.

The Aylsham Manor is a residential care home providing personal care and support for up to 30 people aged 65 years and over, some of whom were living with dementia. At the time of the inspection, the service was full, with one room kept empty for respite care. The service consisted of an extended main house with bedrooms across two floors, and communal facilities, with accessible outside space .

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

People’s care needs continued to not be fully risk assessed or mitigation put in place to manage risks, for example in relation to falls, and aspects of the care environment. When people experienced falls and potentially hit their head, monitoring for signs of head injury were not being recorded to show completion. People were not being supported to maintain healthy weights, as recognised risk assessment tools were not in use.

People were not being protected from the risk of harm, as reporting measures were not being followed by the provider to ensure that referrals were made following incidents and accidents to the local authority safeguarding team; in line with their own policies. People living with dementia were not protected from accessing risk items, such as prescribed creams and teeth cleaning tablets, as the keys to the lockable cabinets were being left in the locks.

People continued not to be protected from the risk of catching infections such as COVID-19, as the provider was not following current government guidance to keep people safe. A person assessed as requiring a specialist diet, was not receiving food in the correct consistencies to mitigate their risks of choking.

The governance systems and processes in place did not ensure that people’s safety was consistently maintained. People were supported to have choice and control of their lives; however, the policies and systems in the service did not ensure staff supported them in the least restrictive way possible and in their best interests. Whilst we found concerns in relation to the safe storage of topical medicines, we found other areas of medicines management had improved. We have made a recommendation regarding areas of improvement for pre-employment risk assessments.

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 Inadequate with breaches of the regulations, (published 21 July 2021). A Warning Notice was served on 16 June 2021 in relation to the breach of regulation 12 for (safe care and treatment), with the timescales for the provider to be compliant by the 16 July 2021. At this inspection enough improvement had not been made and the provider was still in breach of regulation 12 and had not met all the requirements of the warning notice.

At the last inspection, the provider was also found to be in breach of regulations for, staffing, consent, good governance and fit and proper persons employed, which resulted in the provider sending us an improvement plan, and regular updates. We also met with the provider after the last inspection.

At this inspection, whilst some improvements had been made, the provider remained in breach of regulations for safe care and treatment, consent, protecting people from risk of harm or abuse, staff training and supervision and good governance.

This service has been in Special Measures since 21 July 2021. During this inspection the provider demonstrated that sufficient improvements had not been made. The service remains rated as inadequate overall. Therefore, this service remains in Special Measures.

Why we inspected

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

We initially undertook a targeted inspection to check whether the Warning Notice we previously served in relation to Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met.; We inspected and found there was a concern with the provision of safe care, and the decision was made to widened the scope of the inspection to become a focused inspection which included the key questions of the key questions of safe, effective and well-led.

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 previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has remained rated inadequate. 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 The Aylsham Manor 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.

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 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.

The overall rating for this service is ‘Inadequate’ and the service remains 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 rating, 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 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.

The Aylsham Manor is a residential care home providing personal care and support for up to 30 people aged 65 years and over, some of whom were living with dementia. At the time of the inspection, there were 25 people living at the service.

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

People did not receive their medicines safely, and were not monitored following accidents and incidents, even when they had told staff they had hurt themselves or had hit their head. This placed them at risk of harm.

People’s care records listed concerns identified by staff but did not show where follow up action had been taken to ensure people’s health and wellbeing was maintained.

People were not protected from potential harm through relevant safety checks of care, risk assessments and health and safety checks of the care environment. People assessed to be at risk of weight loss, were not being weighed in line with the frequencies identified in their care records. People were not being supported to change their position regularly to prevent the risk of developing pressure ulcers on their skin, where this was an assessed risk.

People were not being protected from the risk of the spread of infections, including COVID-19, due to a lack of procedures and systems being in place, both for people and staff. Some people’s feedback to inspectors that they felt staff should dress more suitably and respond in a timely way when they activated their call bells.

People were not always supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

Due to concerns identified during the inspection, and to maintain people’s safety, a referral was made to the local authority safeguarding team.

Rating at last inspection (and update)

The last rating for this service was Requires Improvement with breaches of the regulations, (published 23 January 2020). The last rating for this service was requires improvement with breaches of the regulation relating to governance, consent to treatment and HR processes for employing staff. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

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 have found evidence that the provider needs to make improvements. Please see the safe, effective and well-led sections of this full report.

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, Effective 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 inadequate. 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 The Aylsham Manor 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 safe care and treatment, consent to treatment, safe appointment of staff, staff training and competency and governance processes and procedures 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 work alongside the provider and 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 ‘Inadequate’ and the service is therefore 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 rating, 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.

The Aylsham Manor is a residential care home providing accommodation and personal for care to up to 30 people aged 65 and over. At the time of the inspection 27 people were using the service some of whom were living with dementia. The accommodation is in a period property which has been extended. Accommodation was provided over two floors with several communal living rooms and dining rooms. People had ensuite toilets and most people also had an ensuite shower. There were also communal bathroom facilities.

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

Systems and processes to manage the quality of care were not always robust. Action was not always taken when audits highlighted shortfalls in records of care. Care records and risk assessments did not always contain the detail staff needed to care for people. People and staff told us managers were responsive and listened and acted on their concerns. There was a person-centred ethos within the home and staff were encouraged to get to know people well. Relatives described the home as having a good atmosphere and being ‘loving and caring.’

The policies and systems in the service did not always support people to have maximum choice and control of their lives and for decisions to be made in their best interests. Staff had the skills and knowledge to support people. However, some of their training was not regularly refreshed. The provider took prompt action to rectify this. People told us the food was good and the cooks had a good knowledge of people’s special dietary requirements and allergies. The service worked well with other professionals to ensure people were able to access support both for physical and mental healthcare needs. The premises were adapted to people’s needs and the provider had an ongoing refurbishment programme to improve the building creating a homely environment for people.

Appropriate checks were not always carried out when staff were employed to make sure they were suitable to work in the service. Risks to people were identified and staff understood how to manage them but records about how to mitigate risks were not always up to date and complete. We made a recommendation about reviewing risk assessments for people who may not understand the risks associated with toiletries. Risks relating to the environment were well managed. People told us they felt safe in the service. Staff were trained and competent in administering medicines as they were prescribed. The home was clean and high standards were maintained in relation to infection prevention and control. When things went wrong incidents were recorded and action was taken to update care plans or risk assessments. The provider kept oversight of incidents to identify patterns and learn lessons to prevent things happening in the future.

People described the home as having a friendly and warm atmosphere. Staff knew people well and developed positive relationships with people and their relatives. People and relatives were involved in decisions about their care. Staff were very aware of promoting people’s privacy and dignity. People were supported to be as independent as possible including maintaining links in the local community.

The service was responsive to people’s needs. Care plans were personalised and contained a detailed overview of each person’s life. Staff were kept informed of changes to people’s needs through handovers and good communication between staff and managers throughout each shift. The home used pictorial signage to help people find their way around the home. There was an active programme of activities that both people and relatives were encouraged to take part in. The registered manager and provider dealt with concerns promptly. The service provided end of life care and had recently been nominated for an award for their work in this area.

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 22 February 2017).

Why we inspected

This was a planned inspection based on the previous rating.

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

Enforcement

We have identified breaches in relation to the need for consent, the employment of fit and proper persons and good governance. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and 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.

This unannounced inspection took place on 29 November 2016.

There was a registered manager in post at the time of this inspection. Although they were unavailable at the time of 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 2008 and associated Regulations about how the service is run.

Risk assessments provided information for staff about how to manage risks to people. Accidents and incidents were being reviewed to reduce the risk of any reoccurrence.

People received their prescribed medicines in a timely manner and medicines were stored and disposed of in a safe way.

The provider had a recruitment process in place and staff were only employed within the service after all essential safety checks had been satisfactorily completed. People were safe and staff were knowledgeable about reporting any incident of harm. People were looked after by enough staff to support them with their individual needs.

People were provided with a good choice of meals. When necessary, people were given any extra help they needed to make sure that they had enough to eat and drink to keep them healthy.

Staff referred people appropriately to healthcare professionals.

The Care Quality Commission (CQC) is required by law to monitor the Mental Capacity Act (MCA) 2005, Deprivation of Liberty Safeguards (DoLS) and to report on what we find. The provider was acting in accordance with the requirements of the MCA including the DoLS. The provider was able to demonstrate how they supported people to make decisions about their care. Where people were unable to do so, there were records showing that decisions were being taken in their best interests. DoLS applications had been submitted to the appropriate authority. This meant that people did not have restrictions placed on them without the correct procedures being followed.

Although care plans were brief, staff knew how to meet people’s current needs. Staff were trained, supported and supervised to do their job. Staff treated people with dignity and respect.

Audits were regularly carried out to assess what improvements were needed to improve the quality of the care people received. Action plans had been put in place as needed.