Ashley Grange Nursing Home

Ashley Grange Nursing Home is a residential care home providing personal and nursing care for up to 55 people. The service provides support to people living with dementia. People are accommodated in one building, over two floors. At the time of our inspection there were 28 people using the service.

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

The provider had developed detailed action plans to address the shortfalls identified at the last inspection. The plans included information about who was responsible for completing actions and had been regularly reviewed to ensure they were on track. Progress to complete actions was overseen by the registered manager and operations manager. The provider had taken the immediate action needed to meet the requirements of the warning notice we served following the last inspection. Further action is needed to ensure these improvements are sustained over time and people receive a consistently good service.

People felt safe at Ashley Grange. The provider had systems to manage risks people faced and help keep them safe.

The home was clean and the provider was undertaking renovation and redecoration. Further work was needed to ensure environmental safety checks were completed consistently and all fire fighting equipment was regularly serviced.

There were enough staff available. Staff had a good understanding of people’s needs and how to meet them. New staff were thoroughly checked before starting work in the home and given a good induction.

People were supported to take any medicines they had been prescribed.

Infection prevention and control procedures had been reviewed and updated to reflect the COVID-19 pandemic and changed as government guidance had changed. Systems were in place to prevent visitors catching and spreading infections.

Staff demonstrated a good understanding of people’s individual needs and a commitment to provide the care people needed.

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.

There were effective management systems in place to monitor how the service was operating and plan the improvements that were needed. Relatives and staff told us the management team had consulted with them and made improvements since the last inspection.

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 (published 1 December 2022). This service has been in Special Measures since 28 October 2022. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This inspection was carried out to follow up on the warning notice we served on the provider following 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.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from inadequate to requires improvement based on the findings of this inspection.

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

Follow up

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

Ashley Grange Nursing Home is a care home providing personal and nursing care for up to 55 people. People are accommodated in one building, over two floors. The service had a contract with the local authority to support local hospitals with an early discharge programme. People were transferred to the service for a programme of rehabilitation prior to being discharged home or to other long-term care. 15 beds were allocated to this initiative. At the time of the inspection there were 38 people using the service.

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

People, relatives and staff consistently told us staffing levels were not sufficient to meet people's needs. The provider told us they used a dependency tool to calculate staffing numbers, which was aligned to dependency needs. While this showed sufficient staff were deployed, this was not our experience and the feedback received during the inspection. Risk assessments had been completed but had not always identified risks to people and plans did not always show how staff managed risks. There was a risk of cross contamination because some equipment and furnishings needed repair or replacement and were difficult to keep clean. Staff understood their responsibilities to protect people from harm and abuse. Safe recruitment practices were in place. Systems were in place for people to receive their medicines in a safe way.

People were not always supported to have enough to eat and drink. People were not 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. There was evidence of collaborative working and communication with other professionals to help meet people's needs.

People spoke highly of the staff. Staff spoke with compassion about the people they supported. People's rights to privacy, dignity and independence were not always promoted. People’s preference for male or female staff for support with personal care had not always been sought.

People did not always receive personalised care which met their needs, and care planning was not always effective. Records did not always show that care and support was provided in line with care plan guidance. People gave mixed feedback in relation to activity provision. There were opportunities for people, relatives and staff to give their views about the service.

The quality assurance systems in place were not effective because although areas for improvement had been identified, and action plans written, they had not been implemented. Staff consistently told us they did not feel valued or recognised by the provider.

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

Rating at last inspection

At the last comprehensive inspection, the rating for this service was Good (published 16/07/2019).

Why we inspected

The inspection was prompted in part due to concerns received about people’s support. A decision was made for us to inspect and examine those risks.

You can see what action we have asked the provider to take at the end of this full report.

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.

The overall rating for the service has changed from Good to Inadequate. This is based on the findings at this inspection. We have found evidence that the provider needs to make improvement. Please see the Safe, Effective, Caring, Responsive and Well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Ashley Grange Nursing Home on our website at www.cqc.org.uk

Enforcement and Recommendations

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 have identified breaches in relation to staffing, safe care and treatment, meeting nutritional and hydration needs, need for consent, person centred care and good governance.

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.

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

We found the following examples of good practice.

The provider was following best practice guidance in terms of ensuring visitors to the home did not spread COVID-19. Staff were adhering to personal protective equipment (PPE) guidance and practices.

Communal areas were well spaced and people, with support from staff were encouraged to maintain social distancing. Clear plans were in place for those who may be required to self-isolate. For those people who may struggle with isolation additional support would be provided.

The service had systems in place for safe visiting to allow people to see and speak to their friends and relatives.

Staff continued to support people to access healthcare, and arrangements were in place should people need to attend hospital safely.

We found the following examples of good practice

• The provider had built a visiting pod at the front of the building. The pods had glass screens and hearing loops, which meant visitors did not have to wear face coverings as they were in a separate space to people. This enabled people to have visitors in a safe and distanced environment. Visitors were booked in at a specified time and the pods were disinfected between visits to avoid potential infection transmission with other visitors. The provider had obtained specialist chairs to ensure those people who usually remained in bed could still use the visiting pods.

• People had also been supported to maintain contact with friends, family and local community groups through phone, video calls and letter writing. The person we spoke with told us, "The staff are doing everything they can to keep us safe from the virus. They are also keeping us entertained."

• The provider had developed a separate staff testing area so staff could be tested without the need to enter the building. This helped to reduce the risk of infection transmission throughout the building.

• The provider had made significant changes to the layout of the building, including creating separate zones with specific staff teams to minimise the interaction between people. Further work was being completed to build an additional kitchenette in one area of the home. This will enable staff to support people with developing their independence/rehabilitation, whilst maintaining the separate zones that have been established in the home.

Ashley Grange Nursing Home is a care home providing personal and nursing care for up to 55 people. At the time of the inspection 49 people were living at the home. Of the 49 people, 10 were receiving care on a short-term basis, following a hospital admission.

The home was in a village setting. People had access to a garden with countryside views. Bedrooms were located across two floors. There were communal lounge and dining areas.

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

On the first day of the inspection we raised some concerns with the management team. These concerns related to observations of care which did not promote people’s dignity or nutritional intake. When we returned to the home, action had been taken to address all areas identified. The actions taken promoted an improved standard of person-centred care.

The home’s call bell system was loud and potentially intrusive, particularly on the first floor of the home. The system also lacked the function to monitor how long people were waiting for assistance. The managing director told us they were in the process of researching an updated call bell system.

The managing director provided assurances the use of agency staff had reduced in recent weeks before the inspection.

The management team were part of working groups to aid compliance with the Mental Capacity Act 2005 (MCA). The management team were seeking advice from professionals to aid their learning about the MCA.

People were supported to have maximum choice and control of their lives. Staff supported them in the least restrictive way possible and in their best interests.

There was a project in the early stages to improve ‘wayfinding’ in the home. The management team were working with art students from a local university. The project will aim to collaboratively develop the environment and make it more dementia friendly. Improvements in signage were made during our visit, with the addition of privacy door notice to bathrooms, to identify when they were in use.

There was work taking place around the appropriate use of language and the use of health and social care terminology in the home. People and their relatives were provided with a ‘jargon buster’. This detailed the types of terminology they may hear of or see in health and social care settings.

The home had an electronic care planning and record keeping system. Staff were confident in using the system and knew where information should be recorded. Records could be searched to gain an overview of the person’s care. For example, a person’s food and drink intake over a period of time.

Staff and the management team knew people well. People’s life histories were known. The impact a personal history may have on a person’s mannerisms or behaviours were understood.

Where people’s health or wellbeing showed signs of change, the management team were quick to recognise this. Referrals were made to the GP or other professionals in a timely manner. People benefitted from a weekly GP round at the home.

We observed some kind and caring interactions. Staff supporting people with their lunch did so at a gentle pace, engaging with the person.

The home was clean, tidy and free from unpleasant odours.

People receiving intermediate care at the home had been supported to achieve positive outcomes. Professionals gave positive feedback about the intermediate care people had received.

An electronic medicines management system was in place. This provided greater accuracy and reduced the likelihood of errors which may be associated with paper records.

The management team completed audits of the service and had a continual improvement plan. Where our inspection identified areas for improvement, these were known by the management team. There were actions planned to address them, or action was taken promptly following our feedback.

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 4 May 2018).

Why we inspected

This was a planned inspection based on the previous rating.

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.

No risks or concerns were identified in the remaining key questions through our on-going monitoring or during our previous inspection, so we did not inspect them. The ratings from the previous comprehensive inspection for these key questions were included in calculating the overall rating in this inspection.

Ashley Grange Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or 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 Grange Nursing Home accommodates 55 people in one adapted building. The building comprises of an older property with a newer extension added. It is on the outskirts of the village of Downton and set in landscaped gardens. At the time of our inspection, there were 40 people living at the service and nine people staying at the service temporarily. One person was staying at the service on respite, which enabled their carer to have a break from their caring role. The service also had eight rooms that had been designated for ‘intermediate care’. This was for people who had been discharged from hospital but required support with rehabilitation for a short period of time before they could move back to their own home. People were also referred by their GP to use ‘intermediate care’ from their own homes when they became unwell. This helped to prevent unnecessary hospital admission. People could have the support they needed to regain their independence before moving back home.

There was a registered manager in post. 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.

Medicines were managed safely. The service had made the required improvement to make sure topical creams and topical patches were being applied as prescribed. Staff had received training in medicines management and used an electronic system to support administration of medicines.

Staff were aware of their responsibilities in keeping people safe from harm. Appropriate checks were made before staff started work to make sure they were suitable to work in a care setting. There were sufficient numbers of staff working to meet people’s needs.

Risks had been assessed and measures put in place to keep people safe. There were also comprehensive risk assessments in place to make sure the environment was safe and regular checks were completed to maintain safe working systems.

The service was clean and free from odours, there were cleaning schedules in place to cover all areas of the service. Staff had access to personal protective equipment such as gloves and aprons and we observed they wore these when appropriate.

The service was well-led with an established and experienced senior management team. Quality monitoring was completed regularly in a range of areas. Feedback was sought from people, relatives and visiting professionals. The service was open about what feedback had been received and action they were taking to make improvements.

Community links were established with a local day service being welcomed one day a week. This enabled people to maintain relationships with old friends and keep in touch with life in the village.

During the last inspection in September 2015, we found breaches of some of the legal requirements in the areas we looked at. Improvements were seen during this inspection which demonstrated the service had responded to our feedback and had implemented improvements in line with their action plan.

The inspection took place on 10 and 11 October 2016 and was unannounced.

A registered manager was employed by the service. 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. The registered manager, managing director and operations director were present on both days of the inspection.

The ordering and disposal of medicines was managed effectively. However, the storage of medicines requiring refrigerated storage was not well managed. This was addressed during the inspection and processes immediately put in place to correct this.

People told us they felt safe when receiving care. Staff were able to tell us how to recognise signs of potential abuse and what action to take if they had any concerns. People’s risk assessments had been completed and recorded in people’s care files. Where accidents and incidents had occurred, these were documented and followed up as required.

There were sufficient numbers of suitable staff to support people however, people, their relatives and staff told us agency staff were often deployed, especially at evenings and weekends. People and their relatives told us agency staff did not have the same understanding and knowledge of how to care for people as regular staff and at times they waited longer for assistance. People who used the service and their relatives were positive about the care they received from regular staff and told us they had sufficient knowledge to provide support and keep them safe.

Staff received regular training in relation to their role and the people they supported and told us this training supported them to do their job effectively. Staff received regular supervisions and an appraisal where they could discuss personal development plans. This meant staff received the appropriate support to enable them to provide care to people who used the service.

People were encouraged to make decisions and staff gained people’s consent prior to carrying out any tasks. The service had a clear understanding on the requirements of the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DoLS).

There was a choice of drinks, snacks and meals available and people told us they enjoyed the food.

Information on people who had been assessed as having poor fluid intake was communicated within the team and this information was also available in people’s nutritional risk assessments. Although concerns relating to people’s fluid intake were communicated to staff some of the documentation to monitor how much people were drinking was not consistently completed.

People had access to health services and a GP performed weekly visits to the home with additional visits according to any changing healthcare requirements. Health and social care professionals spoke positively about the service. They told us they were promptly informed when there were changes to a person’s health and worked well as a team to ensure people received care according to their current health needs.

People and their relatives spoke positively about the care and support they or their family member received. Throughout our visit there was a relaxing and pleasant atmosphere and we saw people were treated in a kind and caring way. Staff had a good understanding of people’s needs. They knew their preferences and offered people choices.

People received care which was personalised and responsive to their needs. Care plans were individualised and contained information on people’s preferred routines, likes, dislikes and also included information on their current and past medical history. Records showed people and their relatives were involved in the planning of their care and care plans were regularly reviewed and updated as required.

People, their relatives and staff were encouraged to share their views on the quality of the service. The service responded to feedback and suggestions and communicated these through regular newsletters and meetings.

People, their relatives and staff spoke highly of how the service was managed and told us the management team were approachable and acted on any concerns promptly and effectively. There were systems in place to monitor and improve the quality and safety of the service provided. Where actions to improve the service had been identified, these had been acted upon.

We found a breach of the Health and Social care Act 2008 (Regulated Activities) Regulation 2014. You can see what action we told the provider to take at the back of the full version of this report.

Priority was given to people's nutritional needs. There was an emphasis on meeting people's dietary requirements and individual personal preferences. A high level of food was cooked 'from scratch' using fresh ingredients. The chef regularly met with people to gain feedback about the meals.

All areas of the home including those areas less visible were clean. There were clear systems in place to manage the risk of infection. Staff received infection control training on an annual basis.

People were positive about the staff team. We observed good interactions between staff and people who used the service. Staff were friendly, caring and attentive in their manner. People were well supported yet there were lengthy delays in some people receiving their lunch time meal. Staff commented they were particularly busy at weekends and key times of the day.

People and their relatives were encouraged to raise concerns if they were not happy with the service they received. There was a clear, organised system for managing complaints. There were forums such as relative meetings to share views, make suggestions and gain support.

All staff trained in basic dementia awareness. A visitor said their relative 'doesn't really know what she wants to do; the staff have the skills to get her doing things'.

People in the home told us they had a wide choice of breakfast. A visitor told us that the tea time meal had been changed to a buffet style meal with a variety of finger foods. Staff and people in the home told us teatimes had become enjoyable sociable occasions.

The service had effective ways of gathering the people's views and using this information in planning improvements. A visitor told us 'You can see how our meetings result in things happening'. Identified shortfalls were identified, rectified promptly and learnt from.

The home employed a person for promoting activities. We saw the person engaging with people all around the home, individually and in small groups. Two people who lived in the home told us about a minibus trip they had joined the previous day. One person told us they enjoyed quiet time when they wanted it and joined in games and exercises when they felt like it.

We found that staff were clear about whistle blowing arrangements and their responsibilities. A nurse told us care staff were good at reporting concerns.