The inspection was unannounced and took place on the 16 August 2018. At the last inspection on the 5 March 2018 and 6 March 2018 we found five breaches in Regulations. The provider breached Regulations because they had not ensured that decisions were made in people’s best interests, people’s risks were not mitigated to keep them safe, nutritional risks were not monitored effectively and there were not enough suitably skilled staff to meet people’s needs in a timely way. We also found that the service lacked monitoring systems to enable poor care to be identified.

Following the last inspection, we served a Notice of Decision to place restrictions on admissions to the service and requested weekly update from the provider to show the actions in place to make improvements to the care people received and to meet the Regulations. At this inspection, we found that improvements had been made to meet the regulations. However, some further improvements were still required.

Ash Hall Nursing home 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.

Ash Hall Nursing Home accommodates up to 60 people in one adapted building. At the time of the inspection there were 34 people using the service.

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

There was a registered manager at the service who was available on the day 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.

Further improvements were needed to ensure that the systems implemented to monitor and mitigate risks to people were imbedded and sustained within the service.

Improvements were needed to ensure people’s medicines were managed and monitored effectively to keep people safe.

Improvements were needed to ensure people’s preferences and diverse needs were included in their care records to enable individualised care provision.

Improvements were needed to ensure that people’s end of life wishes were assessed and recorded.

The provider had taken action to ensure the environment was safe and they had plans in place to make further improvements to the environment to ensure it met people’s needs.

Risks to people’s health and wellbeing were identified, managed and followed to keep people safe from harm.

There were enough suitably recruited staff available to deliver people’s planned care and to keep them safe. Staff had received training to enable them to carry out their role effectively.

People were safeguarded from abuse because staff knew how to recognise and report potential abuse. Infection control risks had been reduced to protect people from the risk of avoidable infections.

When people did not have the ability to make decisions about their care, the legal requirements of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS) were followed. This meant people were supported to have as much choice and control of their care and treatment in their best interests.

People’s nutritional risks were mitigated and advice was sought from health and social care professionals when people were unwell.

People told us they were treated with care and compassion. People were treated with dignity

The inspection took place on the 5 March 2018 and 6 March 2018. The inspection was unannounced. At the last inspection we found breaches in regulations. The service were not ensuring that people were consenting to their care and where unable processes were not in place to ensure decisions were made in people’s best interests. We also found that the service lacked monitoring systems to enable poor care to be identified and mitigated. Following the last inspection, we asked the provider to complete an action plan to show how they would meet the regulations and when they would be compliant. At this inspection, we found that the required improvements had not been made and we found further breaches in Regulations.

Ash Hall Nursing home 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.

Ash Hall Nursing Home accommodates up to 60 people in one adapted building. At the time of the inspection there were 45 people using the service.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

There was a registered manager at 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.

At this inspection we identified breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the 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.

There was a lack of governance in the service and the provider did not have effective systems in place to consistently assess, monitor and improve the quality of care. This meant that poor care was not identified and rectified by the manager and provider.

Risks to people’s health and wellbeing were not consistently identified, managed or followed to keep people safe.

We found there were not enough staff available or eff

We inspected this service on 19 December 2016. This was an unannounced inspection.

The service was registered to provide nursing and accommodation for up 53 people at the time of our inspection 48 people were using the service.

The service had 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.

When needed people did not always have capacity assessments or best interest decisions in place. Staff did not demonstrate an understanding of DoLS or how to support people in the least restrictive way whilst approvals were considered.

Risks to people were not always managed safely. When people had been assessed to use equipment they were not always supported to use the correct type. When people had behaviours that may challenge there was no guidance for staff to follow to offer a consistent approach. There was no guidance available for staff when people needed as required medicines to ensure people received this medicine appropriately.

Staff did not always receive formal supervision and some staff training was out of date and had not been updated. Staff did not always know people’s preferred routines. The systems in place to monitor quality of the service had not been completed and were not always effective to identify areas of improvement. The provider did not formally seek feedback from people who used the service to make changes based on their opinions. The provider had not ensured that staffing shortfalls in the home had been addressed to ensure the management tasks in the home could be completed.

Staff knew how to recognise and report potential abuse and staff suitability to work within the home was checked by the provider. There were enough staff available to offer support in a timely manner. People were happy with the staff and were treated in a kind and caring way. People were encouraged to be independent and make choices about their day. People’s privacy and dignity was upheld.

People enjoyed the food and were offered a choice. Relatives and visitors felt welcomed and could visit anytime. People were happy with how they received their medicines. When needed people had access to health care professionals. People knew how to complain and felt happy to do so. The provider ensured complaints were responded to in line with their policy. People were happy with the activities that were offered within the home.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

We met with the provider, the registered manager, care staff, nurses and catering staff. Staff told us that they liked working at the home that they felt supported and equipped with the skills to do their job. One staff member said, "The manager is approachable and supportive and staff training is good."

People who used the service told us that the staff were caring and helpful and supported them with their personal and nursing needs. A visitor commented, "I think the care X gets here is very good. They look after her very well."

We met with two commissioners of care during the inspection and they were satisfied with the level of care and support provided. They also thought that records of care were good. They had no concerns about how people were cared for by the provider.

We saw that the provider had made improvements to the outcomes where we had previously assessed them as non compliant. We found that they were now compliant in these areas.

We saw that the dining experience had improved overall but that people felt that the choices of food on offer could be better.

We saw that care was delivered in a task orientated way rather than on an individual basis. The provider could look at how people could receive individual care and support in a way they would prefer it.

The provision of staff had improved at the home but some people felt that they were sometimes waiting too long for attention. The provider could look at how this could be further improved.

People told us what it was like to live at this home and described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people living in care homes are treated with dignity and respect and whether their nutritional needs are met.

The inspection team was led by a Care Quality Commission (CQC) inspector joined by an Expert by Experience, who has personal experience of using or caring for someone who uses this type of service, and a practising professional.

A number of people who used the service had varying levels of dementia, so not everyone was able to tell us about their life at the home. To help us understand people's experiences we used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experiences of people who could not talk with us.

We were able to speak to nine people and three relatives. All but one of the people we spoke with told us that they were very happy at Ash Hall. One person said, “They can’t do enough for you”. Another person told us that they were fine living at the home and felt safe. They told us they were, “Very happy and content.” Another person told us that, “They are really lovely here – they are, honestly”.

We spoke with five members of care staff. They had a good understanding of the types of abuse and their role in keeping people safe. The ongoing training of care staff reflected some of the specific needs of people living at the home. Care staff respected the day to day choices people were able to make and how their independence could be supported. People’s dignity was not always respected. We did not see any privacy screens available in shared rooms. One person was assisted to the toilet and then left unsupervised for a short while, with the door left open.

On the day of the inspection, care staffing levels did not provide adequate support at mealtimes. There were also a number of delays in calls for assistance being responded to across the day. People’s experiences at mealtimes varied. People who were dependant on staff support at mealtimes were not always able to eat their meal without distractions due to the number of people requiring assistance in and out of the dining room and the number of journeys between dining rooms with people’s meals. We saw that some people who needed assistance with eating had individual help from staff who were attentive and patient. Other people were rushed through their meal, with little encouragement or engagement being provided by staff.

We found there were care records for each person living at the home. The general quality and accuracy of care plans and records needed to improve. It was sometimes difficult to check that care provided continued to meet people's needs. Action was not always taken to identify a dietary plan for people where there were concerns with their weight loss, so that people were helped to eat sufficient amounts.