About the service:

Ash Grange is a nursing home that provides accommodation and personal care and support to a maximum of 42 people. The service provides care and support for older people some living with dementia. At the time of our inspection 39 people were living at the service.

People’s experience of using this service:

• People felt safe living at the service and staff understood how to protect people from the risk of harm or abuse. People’s care and health needs were assessed and known by staff. People were supported by sufficient numbers of safely recruited staff. People received their medicines as prescribed.

• Staff had the skills to meet people’s needs and acted promptly to refer people to healthcare professionals when required. People had a choice of food and drink and were supported to maintain a healthy diet which met their needs and preferences. Staff sought people’s consent before providing care.

• People said staff were kind and caring in their approach. People were supported to be as independent as possible and said they felt listened to and their views and opinions respected.

• Care records were personalised and reflective of a person’s needs. People were supported to take part in a range of activities and hobbies. People were supported to maintain relationships that were important to them and visitors were welcomed at the service. People and their relatives knew how to make a complaint and were confident that action would be taken.

• People, their relatives and staff said the service was well led and the management team open and approachable. The service had a culture of continually improving the quality of care people received and robust care planning and quality assurance systems were in place. The service has improved from a requires improvement rating at our last inspection to Good.

Rating at last inspection:

Rated Requires Improvement overall (27 April 2018)

Why we inspected:

This was a planned inspection based on the rating at the last inspection. At this inspection we found the service met the characteristics of Good in all areas.

Follow up:

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

We carried out this unannounced inspection on 21 and 23 February 2018. Ash Grange is a care home with nursing. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premised and the care provided, and both were looked at during this inspection. Ash Grange provides care and support for up to 42 people some of whom are living with dementia. On the day of the inspection 29 people were living at the home.

At our last inspection in August 2017we identified significant improvements were needed throughout the service. We judged the home as ‘Inadequate’ in all five of our key questions and identified 8 breaches of the Health and Social Care Act 2008 and one breach of the Care Quality Commission (Registration) 2009. We identified a number of concerns under each of the key questions we inspect. We found under the key question is the service ‘safe’ there were not enough staff to meet people’s needs safely. We also found people’s needs had not been assessed or managed to reduce the risk of avoidable harm; and people did not receive their medicines as prescribed. Under the key question is the service ‘effective’ we found staff did not always have the skills and knowledge to meet people’s health and support needs. We found people did not have their rights upheld in line with the Mental Capacity Act (MCA). We also could not be assured people were getting sufficient to eat and drink and their health needs were not monitored effectively. Under the key question is the service ‘caring’ we found people did not always receive their support in a caring way and their privacy and dignity was not respected. Under the key question is the service ‘responsive’ we found people did not receive care that was responsive to their needs. We also found the complaints system was not effective to investigate concerns or complaints raised. Under the key question is the service ‘well led’ we found the systems and processes to monitor the safety and quality of care people received was not effective. We found little evidence of feedback being sought from people to drive forward improvements. We also found the provider had failed to notify us of incidents as required by the law.

Following our August 2017 inspection we placed the home in special measures and met with the provider and asked them to complete an action plan to show us what they would do and when by to improve all the key question(s) to at least “good.” 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.

Since our last inspection the registered manager and deputy have left the home and the home is currently being managed by an interim manager and team. This meant the home does not currently have 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.

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. We found the service was now meeting the regulations.

People told us they felt safe and staff knew how to report concerns and escalate risks about people’s safety. Risks to people’s health and care needs were assessed and effectively managed. There were sufficient numbers of staff available to meet people’s needs. P

This inspection was unannounced and took place on 16 and 19 August 2017. The inspection was prompted in part by a notification of an incident following which a person using the service sustained a serious injury. The information shared with CQC about the incident indicated potential concerns about the management of people’s care needs. This inspection examined those risks.

Ash Grange Nursing Home is registered to provide accommodation for 42 older people some of whom are living with dementia. On the days of the inspection there were 39 people living at the 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.

People were not safe. There were insufficient levels of staffing to meet people’s health and care needs. Risks were not consistently identified, assessed or managed which meant some people were at risk from avoidable harm. People were not always protected from the risk of abuse because incidents were not always reported to the local safeguarding authority. People did not always receive their medicines as prescribed.

People received support from staff that did not always understand how to meet some people’s care needs. Staff did not always seek people’s consent before providing care. Principles of the Mental Capacity Act 2005 had not been followed when people lacked the capacity to make specific decisions. People did not always have their food and drink managed safely. Staff did not always follow the guidance provided by healthcare professionals when supporting people.

People were not supported in a caring manner. Staff did not always support people in a dignified way and people’s rights to privacy were not always respected by the staff. Staff did not have time to build meaningful relationships with people. Some language used by staff to describe people and their care needs was not dignified. People were not involved in making choices about how they wished their care and support to be delivered.

People did not always receive care that was responsive to their individual needs. People sat for long periods of time without any stimulation. There were minimal activities available to people; staff were rushed, task focused and missed opportunities for interaction with people. People and their relatives knew who to contact should they wish to raise any complaint or concern. However the provider had failed to investigate complaints or respond appropriately to people’s concerns.

Systems used to monitor the quality of the home were not effective at identifying concerns and protecting people from risks to their health, safety and well-being. The provider had failed to notify us of events as required by law. Communication systems used within the home were not effective in managing risks to people.

During this inspection we identified 8 breaches of the Health and Social Care Act 2008 and one breach of the Care Quality Commission (Registration) 2009. You can see what action we told the provider to take at the back of the full version of the 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

The inspection took place on 21 July 2016 and was unannounced. We last inspected this home on 22 and 24 April 2015, where we found the provider was meeting the regulations.

Ash Grange provides nursing and personal care for up to 42 older people, including people who have dementia. Whilst most people live there permanently, the service also provides care to people on a short term basis when they are discharged from hospital. At the time of our visit there were 41 people living at the service. There was a registered manager in post at the time of our 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.

There was not always enough staff to meet people’s needs in a timely manner. People told us they felt safe. Staff we spoke with were aware of their responsibilities to report any concerns of potential abuse. Risks to people had been assessed and appropriate equipment was available for staff to use. People told us they received their medicines safely. Staff responsible for administering medicines had received relevant training. The provider had safe processes in place to recruit new staff and carried out appropriate pre-employment checks. Staff undertook training to ensure they were able to carry out their role effectively.

Staff obtained consent from people before they provided care. Staff understood people’s choices and decisions when supporting them. People told us they were supported to eat and drink sufficiently. People had access to other health care professionals to ensure their healthcare needs were met. People told us they were involved in the planning and review of their care. However records did not always contain specific information and guidance for staff to refer to.

People said staff were kind, caring and treated people with dignity and respect. People were involved in group or individual social activities to prevent them becoming isolated. Staff supported people’s independence. People felt listened to and were involved in giving feedback about the quality of the service. People and relatives were confident that if they had any concerns or complaints, they would be listened to and the matters addressed quickly.

People and relatives felt the home was well managed and staff understood their roles and responsibilities. The provider had management systems in place to assess and monitor the quality of service provided.

One inspector carried out this inspection. Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read our full report.

Is the service safe?

People told us they felt safe. Safeguarding procedures were robust and staff understood how to safeguard people they supported.

People told us that they felt their rights and privacy were respected. One person said, "I love living here. We're treated as individuals and they know what we like."

Systems were in place to make sure that managers and staff learned from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations.

Staff knew about risk management plans and discussed situations in which they had followed them. People were not put at unnecessary risk but also had access to choice and remained in control of decisions about their care and lives.

The registered manager set the staff rotas and they took people’s care needs into account when making decisions about the numbers, qualifications, skills and experience required. This helped to ensure that people’s needs were always met.

Policies and procedures were in place to make sure that unsafe practice was identified and people were protected.

Staff records demonstrated that mandatory training was up to date and that staff were trained sufficiently to meet the needs of people who lived there. Staff were trained in caring for people with dementia and challenging behaviour. The home did not have any people living with a Deprivation of Liberty Safeguards authorisation in place but staff had been trained in the correct procedures to follow if this situation changed.

Is the service effective?

People’s health and care needs were assessed with them, and they were involved in writing their care plans. Where people did not have the capacity to consent to care, there were procedures in place to ensure that decisions were made in the best interest of the person.

Specialist dietary needs had been identified where required. People said that their care plans were up to date and reflected their current needs. Staff told us that care plans were personalised which helped them to understand how to provide care in a way that respected the person's personality, likes and dislikes.

Is the service caring?

We spoke with people who lived in the home and spent time observing them being cared for by staff. We asked them for their opinions about the staff that supported them. Feedback from people was positive, for example, “I like everything here. The staff are so lovely, I enjoy sitting chatting to them.” And, "The staff are brilliant, I'm well looked after."

When speaking with staff it was clear that they genuinely cared for the people they supported. People using the service, their relatives and other professionals involved with the service were able to be involved in regular meetings with staff. Where shortfalls or concerns were raised these were taken on board and dealt with.

People’s preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people’s wishes.

Is the service responsive?

People knew how to make a complaint if they were unhappy. One person said that they had never made a complaint but knew how to do so. We found that previous complaints had been dealt with appropriately by the provider and resolved in the best interest of people who lived there.

The service worked well with other agencies and services to make sure people received care in a well-structured way.

Is the service well-led?

The service had a quality assurance system, and records showed that identified problems and opportunities to change things for the better were addressed promptly. As a result the quality of the service was continuously improving.

Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home. This helped to ensure that people received a good quality service at all times.

During our inspection we spoke with the deputy manager and two staff members. The registered manager was not available on the day of the inspection.

At our last inspection on 13 January 2013, we found that people’s privacy, dignity and independence had not always been respected.

At this inspection we spoke with people living at the home and visiting relatives. People we spoke with told us that their dignity was maintained and they were respected by staff. We saw that people were involved in giving feedback about the service they received.

One person living at the home told us: "I get very good support. The staff are very good to me".

At our last inspection on 13 January 2013, we found that the provider had put in place some measures to ensure people's safety. However the provider had not made suitable arrangements to ensure that people subject to bed rail restrictions had their needs regularly reviewed.

At this inspection, we found that the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. We saw that people subject to bed rail restrictions had their needs regularly reviewed.

Staff told us they were supported to deliver care safely and to an appropriate standard.

We found that the records we looked at were accurate and fit for purpose.

During our inspection we spoke with the home manager, who had been in post for seven weeks. The manager told us they had identified areas for development to improve standards in the home.

We found morale amongst staff was generally low due to management changes and new ways of working. The manager told us they were aware of this and were working with staff to ensure the impact did not negatively affect people living at the home.

One member of staff told us, “The new management team is making sure things are dealt with professionally. I am passionate about this home and I know that staff care about the people who live here”.

We spoke with people who lived in the home, their relatives, staff and two visiting professionals.

One relative told us, “The care is very good here. The nurses and care staff are great. I am more than happy with the home”.

We checked how people were involved in the service they received. They attended regular meetings and participated in their care reviews. We found that people’s care needs were being adequately met.

We saw that some measures were in place to ensure people’s safety. However people subject to bed rail restrictions were not having their needs regularly reviewed in this respect.

We found there were sufficient staffing levels at the home.

We found that there was an effective system in place for monitoring the quality of the service. This included infection control measures to ensure acceptable standards of hygiene.

We spoke to five people who live at the home and seven relatives. People told us that they were happy living there. One person said us, "It's my home, I am happy here".

People told us how they spend their day. They said that they get up and go to bed when they choose and are able to have their meals in the main lounge/dining room or their bedrooms if they preferred or were unwell. They told us that they enjoy the activities that take place. One person said, "I have company here and am not on my own as I was at home".

People told us that staff are respectful and helpful to them. They told us that staff generally assisted them when they needed it, although they sometimes had to wait to be taken to the toilet.

There is a need for some carpets, floor covering, furniture and other equipment to be replaced to ensure that they can be adequately cleaned to reduce the risk of cross infection.

The home has both double and single rooms and people can choose if they wish to share a bedroom. People are able to personalise their bedrooms to reflect their tastes and interests.

The inspection took place on 22 and 24 April 2015 and was unannounced. We last inspected this home on 30 June 2014, the provider was meeting all the regulations we inspected.

Ash Grange provides nursing and personal care for up to 42 older people, including people who have dementia. At the time of our visit there were 35 people living there. There was a registered manager in post at the time of our 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.

People told us they felt safe living at the home and free from the risk of abuse. Staff we spoke with told us that they understood their role in keeping people safe and they knew how to report concerns. Staff had received training on how to protect people from the risk of abuse.

People, relatives and staff told us that there was not enough staff available at all times to support people with their care needs. The registered manager agreed that reviewing the deployment of staff at peak times would ensure people were supported in a timely manner.

The provider had safe processes in place to recruit new staff and carried out pre-employment checks. Staff completed an induction, received regular supervision and training to ensure they had the skills and knowledge they needed to meet people’s needs.

Risks to people were assessed and equipment was available for staff to use but it was not always used safely to protect people from risk of injury. People received their medicines at the correct time and as prescribed. Medicines were managed, stored and administered safely.

Assessments of people’s capacity to consent and records of decisions had not been completed in their best interests. The provider could not show how people gave their consent to care and treatment or how they made decisions in the person’s best interests.

People and relatives spoken with were happy with the food and felt that they had a choice of what they would like to eat and drink. People’s dietary and nutritional needs were assessed and people were supported to eat and drink sufficient amounts to maintain their health.

People told us staff were kind and caring in their approach. People and their relatives felt listened to and involved in developing a plan of their care needs. Staff worked closely with other healthcare professionals to ensure care plans reflected a person’s health needs. Staff understood people’s choices and preferences and respected their privacy and dignity.

People and their relatives felt comfortable raising concerns with the staff or management team and were aware of the provider’s complaints policy. The provider had an effective process in place to respond to people’s complaints or concerns.

People, relatives, staff and professionals told us the management team were approachable and visible within the home. Relatives and visitors to the home told us they were welcomed by the staff which enabled them to maintain relationships with their family members.

There were audit systems in place to monitor the quality of the home. These included gathering feedback from people who used the service, relatives and healthcare professionals. The registered manager and provider had made regular checks to monitor the quality of care people received and identified areas where improvement may be required.