Ashill Lodge Care Home

Ashill Lodge care home is a residential care home providing personal and nursing care for up to 35 people. At the time of our inspection there were 29 people using the service, most had a diagnosis of dementia. The home had been extended in the last eighteen months to create an additional communal space and 10 bedrooms all with ensuite facilities. The home had a passenger lift and chair stair lift as well as generous outside space.

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

We were given a mixed picture about this service from the evidence collated with most relatives sharing their positive experiences about their family members care, whilst a few relatives were not happy with the service. Through our observations we noted staff were kind and caring, however not always responsive to people’s individual needs.

We found a number of risks associated with people’s safety including unguarded stairs which people could access, hot teapots left unattended, the laundry room with chemicals left open and a stiff fire door which might impede people’s exit in the event of an emergency. People were supported to socialise with each other, and breakfast was observed to be a lively affair. We found however, when staff were busy people were not supervised safely and there was a risk to them or other people. For example, one person was known to go into other people’s rooms, we observed another person picked up a large television from the communal area.

Staffing levels were sufficient during the day, but numbers were significantly reduced at night. Night-time hours had not been reviewed in line with people’s needs and routines. From reviewing records, we identified there was an increase in incidents and falls later in the day and early morning. A twilight shift had been introduced and the provider was introducing an early morning shift as a direct result of increased falls at that time of day.

Medicines management identified continued areas of concern for the second time and concerns were part of a previous breach of regulation 12. This meant we were not assured that robust arrangements were in place to ensure people always received their medicines as directed.

The provider took an active role in the home and knew people, relatives and staff well. They were responsive to feedback and acted immediately on the concerns we raised. They were supported by a deputy and acting manager but there was not a registered manager in post. They had been proactive in sending us regular action plans and were continuously trying to improve their service.

There was a good working relationship with primary health care services who supported the home and told us the home were responsive to people’s needs and felt they identified emerging risks and addressed this quickly. A lot of people had equipment designed to promote their safety such as bed rails and sensor mats.

People were mostly supported to have maximum choice and control of their lives and staff mostly supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. Documentation was in place which demonstrated people were involved in their care and consulted about what they wanted to do. One person was supported outside the home to maintain contact with family and continue to have an active life in the local community. Prior to our inspection we had received concerns about the restrictive visiting hours and the inflexibility of the visiting policy. This was discussed with the provider and the reasons for this understood but we would expect the provider to consider the person’s wishes and circumstances of family members, for example when working full time.

Rating at last inspection and update

The last rating for this service was requires improvement (published 22 March 2019) and there was a breach of regulation 12: Safe care and treatment including medicines management. 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 the provider was still in breach of regulation 12 for the third consecutive inspection.

Why we inspected

This was a focused inspection that considered safe and well led, we found both key questions required improvement. The overall rating for the service has remained requires improvement with breaches of the regulations, based on the findings of this inspection.

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

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment and the governance and oversight of the service at this inspection. We have also made a recommendation about staff records and ensuring that they demonstrate that staff competencies have been adequately assessed for the role they are doing.

Please see the action we have told the provider to take at the end of this report.

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 request an action plan from 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

continue to monitor information we receive about the service, which will help inform when we next inspect.

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

Ashill 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.

Ashill Lodge provides accommodation and personal care to a maximum of 20 older people, some of whom may be living with dementia. Bedrooms are arranged over two floors with a stair-lift between them. This makes parts of the home unsuitable for, and inaccessible to, people with significant difficulties with their mobility. At the time of our most recent inspection there were seventeen people using the service.

At the time of this inspection there was a manager in post who was not yet registered with CQC but their registration interview was imminent. 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.

In summary we found the service was improving and people were confident in the care they received. We identified one repeated breach of regulation for safe care and treatment in relation to medicines. The manager was newly in post and had only been in post for three months. They had worked hard to stabilise the service and boost the confidence and morale of staff. They were very focused on people’s experiences. The quality assurance systems were not yet fully developed and could not clearly demonstrate how they improved the service based on feedback from people. Record keeping needed to be improved to clearly show people’s care needs and how staff were acting consistently to meet them. Staffs knowledge and training required improvement and some staff had not had the support or training they needed in the past so we were not assured of their competency. The environment required some further update but was much improved. The level of activity and opportunity for people also needed improvement.

Since the last inspection there have been two different managers with a third manager starting only recently. We have received a high number of concerns about this service which have recently subsided and there have been genuine attempts to improve the standards of care provided. The service has been supported by the local authority quality monitoring team who recently visited and inspected the service and helped determine what was working well and where the service needed to improve. We found some of the improvements being made were not firmly embedded. We found staff were kind and caring and were being supported to develop their skills and confidence. A new quality assurance lead had been appointed and would oversee the audits and ensure the safety and development of the service. The manager had reviewed the care plans and was developing them to make them more person centred. They had identified training needed by staff and had already put into place staff champions based on their skills and knowledge. Some activities were taking place but these were insufficient and did not support a person- centred approach to care.

The provider was described as supportive and caring to people using the service, even taking people out on occasion They planned to expand and upgrade the service and had made cosmetic improvements. We found the service was mostly safe and well maintained with staff recognising what actions they needed to take if they recognised a person being at risk of harm or actual abuse. Staffing levels were sufficient but a more clearly defined plan for activities was required. Staff mostly had the skills necessary but more investment in training and staff supervision would enable staff to increase their confidence and recognise when a person’s health was not being managed.

The service was working in accordance with the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). The MCA ensures that people’s capacity to consent to care and treatment is assessed. If people do not have the capacity to consent for themselves the appropriate professionals, relatives or legal representatives should be involved to ensure that decisions are taken in people’s best interests according to a structured process. DoLS ensure that people are not unlawfully deprived of their liberty and where restrictions are required to protect people and keep them safe, this is done in line with legislation. We found that staff understanding of MCA and DoLS was adequate and appropriate DoLS referrals had been made for people. Care records around care and capacity needed review to ensure they were not contradictory.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice

You can see what action we told the provider to take at the back of the full version of the report. Please note that the summary section will be used to populate the CQC website. Providers will be asked to share this section with the people who use their service and the staff that work there.

Ashill Lodge provides accommodation and personal care to a maximum of 20 older people, some of whom may be living with dementia. Bedrooms are arranged over two floors with a stair-lift between them. This makes parts of the home unsuitable for, and inaccessible to, people with significant difficulties with their mobility.

There were 14 people using the service when we inspected with one additional person accommodated each weekend. We inspected on 12 and 14 December 2017 and the first day of our inspection was unannounced.

There was no registered manager in post, the previous registered manager having left the home before our inspection. They were in the process of cancelling their registration. 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 (HSCA) 2008 and associated Regulations about how the service is run.

The provider of the service had appointed a new manager who had submitted a successful application to register with CQC. However, shortly after our inspection visits and while this report was being drafted, the new manager left the service. This meant that the director, who was the provider's Nominated Individual with CQC, was responsible as a registered person, for ensuring the satisfactory operation of the service.

The new provider registered with us on 6 February 2017 when they took over the service. This was their first inspection. We acknowledged the very poor standards the new provider found when they started to run the home and that they had made some progress. However, we found that improvements were still needed in all areas.

There were concerns about how people's safety was promoted. Risks to people's safety were not always properly and fully assessed. This included arrangements in an emergency such as a fire. Although staff understood how to administer medicines safely and completed records showing they had done so, people's medicines were not always managed safely. Sometimes people were left without the medicines they had been prescribed.

The director of the service had plans to develop and improve the premises and had already improved some of the décor. Major works to control infection were needed and scheduled. However, there were some areas needing addressing as part of routine day-to-day management.

These concerns represented a breach of Regulation 12 of the HSCA 2008 (Regulated activities) Regulations 2014 for safe care and treatment.

Staff recruitment measures were not robust enough to properly contribute to protecting people from the appointment of staff unsuitable for care work. Appropriate checks were not completed to promote safe recruitment decisions and contribute to safeguarding people from the employment of unsuitable staff. This was a breach of Regulation 19 of the HSCA 2008 (Regulated activities) Regulations 2014 for fit and proper persons employed.

There were systems for monitoring when staff needed to complete training so shortfalls could be addressed. However, staff were not always properly supported, including through supervision and when they were new to the home, to ensure they could support people effectively. This was a breach of Regulation 18 of the HSCA 2008 (Regulated activities) Regulations 2014 for staffing.

People's needs were not always properly and fully assessed and planned for. They were not always involved in planning their own care and their preferences were not always taken into account. People's social and recreational needs were not met. They described themselves as bored and staff were concerned some people were becoming isolated. This was a breach of Regulation 9 of the HSCA 2008 (Regulated activities) Regulations 2014 for person centred care.

There had been a period of stable leadership but this had changed. This compromised the way that the necessary improvements were identified, embedded in practice and sustained. Systems for monitoring the quality and safety of the service and for identifying and addressing risks were not always operating effectively. Action was not always taken promptly and robustly to identify shortfalls and address the failure to meet regulations. This was a breach of Regulation 17 of the HSCA 2008 (Regulated activities) Regulations 2014 for good governance.

The statement of purpose for the service had not been kept up to date and accurate. This was a breach of Regulation 12 of CQC (Registration) Regulations 2009.

You can see what action we have told the provider to take at the back of the full report.

Although not always well documented in care records, staff understood the need to seek people's consent to deliver care in line with the Mental Capacity Act 2005. They recognised the importance of acting in people's best interests. The manager understood the Deprivation of Liberty Safeguards and when applications were needed to protect people's rights.

People had enough to eat and drink. Although choices were not always made clear to people, staff ensured they had access to something to eat that they would enjoy. Staff also promoted other aspects of people's health to ensure they received advice from relevant professionals about their wellbeing.

Staff treated people in a kind and compassionate way. However, they recognised they were not always able to attend to details and "niceties" about people's care that would contribute to promoting their self-esteem. They treated people with respect for their privacy and independence and also understood their obligations to report any suspicions of harm or abuse.

There was a system for managing people's complaints. However, the changes in management arrangements may influence people's awareness of who they should raise their concerns with.