Ashcroft 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.

Ashcroft can accommodate up to 66 people. The home has three floors, the first floor is a unit specialising in the care of people living with dementia.

At our last inspection, we rated the service good. At this inspection, we found the evidence continued to support this rating and in addition, we found the service had improved to outstanding in some areas.

A new registered manager had been appointed since our last 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.

The service was exceptionally caring. Everyone we spoke with was very complimentary about the service and said they would recommend the home. There was a strongly embedded culture within the service of treating people with dignity and respect. This was supported by a number of dignity champions.

Consultation with people was an integral part of the way the service operated. We saw many examples of ways in which people’s feedback had been used to shape the service. We found the provider had adapted the first floor to create an engaging and enabling environment for people living with dementia.

People were protected from harm. Staff knew how to recognise and report concerns about people’s safety and welfare. Any concerns, which were raised, were dealt with properly. Risks to people’s health and safety were identified and managed. When things went wrong lessons were learned and action taken to reduce the risk of this happening again. The recruitment of new staff was done safely, which helped to make sure, only staff suitable to work with vulnerable adults were employed.

People’s medicines were managed safely. The service worked with a range of health and social care professionals to make sure people’s health care needs were met.

The home was clean and well maintained.

There were enough staff and they were well trained and supported to meet people’s needs.

People were supported to eat and drink and offered a choice of food, which reflected their dietary, religious and cultural preferences.

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.

People’s needs were assessed and care plans were in place, which included information about their support needs and preferences. People and their relatives were involved in planning and reviewing the way their care was delivered.

People were offered the opportunity to take part in a wide range of activities both in the home and in the community. In response to feedback from people, the service was working to create a community setting within the home. To this end, they had created an old-fashioned sweet shop, a pub, a cinema room, a traditional lady’s hairdressing salon and a barber shop.

The home benefitted from strong leadership. The registered manager was passionate about providing person centred. The provider had robust and effective systems in place to monitor, assess and improve the quality and safety of the services provided. The management team was continuously looking at ways to improve the service for the benefit of the people who lived there.

Further information is in the detailed findings below.

Ashcroft Nursing Home provides accommodation and personal care for up to 67 older people at any one time. The home is spread over three floors with a dementia unit on the ground floor and a general residential unit on the 1st floor. At the time of the inspection the lower ground floor was not open and was undergoing redevelopment.

This was an unannounced inspection which took place on 17 November 2015, 55 people were living at the service.

At the previous inspection in November 2014, we identified a breach of Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. At this inspection we found improvements had been made and the provider was no longer in breach of any of our regulations.

A registered manager was in place. ‘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 and their relatives told us the service provided safe and appropriate care and treatment. Safeguarding procedures were in place and we saw evidence these were followed to keep people safe. Risks to people’s health, safety and welfare were well managed by the service.

There were enough care staff deployed to ensure people were cared for safely and provided with regular social interaction.

Medicines were safely managed. Staff thoroughly checked medicines before administration to help reduce the risk of errors. People received their medicines at the times they needed them.

People told us that staff had the right skills to care for them. Staff received regular training updates in a range of subjects. Staff we spoke with demonstrated a good knowledge of the people and subjects we asked them about, indicating training was effective.

Since the last inspection, significant areas of the building had been refurbished. The environment was pleasant and well maintained and contained a number of different communal areas where people could spend time.

Following the last inspection the service had opened a dementia care unit on the ground floor. The registered manager had implemented an effective and person centred approach to dementia care. Staff had been provided with dementia, dignity and delirium training and adaptions had been made to the environment to make them more dementia friendly.

The home was meeting the requirements of the Deprivation of Liberty Safeguards (DoLS) and acting within the legal framework of the Mental Capacity Act (MCA).

People spoke positively about the food provided by the service. We saw people were given sufficient choice and provided with regular snacks throughout the day. Appropriate action was taken by the service where people were deemed to be at risk of malnutrition.

Effective links had been developed with external health professionals to ensure that people’s healthcare needs were regularly monitored.

People and their relatives said staff were always kind and caring and treated them well. We observed care and support and saw this was the case. Staff were familiar with the people they were caring for and were aware of their likes and preferences.

People’s needs were thoroughly assessed to assist in the delivery of appropriate care. On reviewing care records, speaking with people and staff we concluded that people were receiving appropriate care which met their individual needs.

A range of activities were provided to people. Activities co-ordinators were employed by the service and social interaction was supplemented by volunteers and students on placements at the home.

On reviewing records and speaking with people and their relatives we concluded people experienced a high level of satisfaction with the service. A system was in place to record, investigate and respond to any complaints received.

People and staff spoke positively about the way the home was managed.

Systems were in place to assess, monitor and improve the service. This included regular audits conducted by team leaders, the registered manager and senior managers. We saw these regularly identified issues and were effective in driving continuous improvement of the service.

Ashcroft Nursing Home provides accommodation and personal care for up to 72 older people at any one time. The home is spread over three floors and set in its own grounds. On the date of the inspection, 12 November 2014, 54 people were living in the service.

At the last inspection in May 2014 the home was in breach of Regulation 9, Care and Welfare and Regulation 22, Staffing of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. We undertook this inspection to check the required improvements had been made.

A registered manager was in place. 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 and associated Regulations about how the service is run.

People spoke positively about the care received in the home and said improvements had been made over the last few months. We found the home now employed more staff which meant they could provide a consistent level of staff for each shift. Staffing levels were now sufficient to meet people’s individual needs.

We found improvements had been made to the level of care and support provided. Care managers were in place to oversee care on each of the units and they reviewed people’s care and support to ensure it was meeting their needs. Although we found improvements had been made to the care and support people received, we found the care people received was not always robustly documented. For example charts monitoring people’s fluid intake were poorly completed on the nursing floor and records of the topical medicines people received were not always consistently documented.

This was a breach of Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.

People were protected from abuse, because staff had received appropriate training and understood the actions needed to protect people. Risk assessments were in place which considered the risks to each person and how to manage those risks in order to keep them safe.

Medicines and the premises were managed safety.

The home was meeting the requirements of Deprivation of Liberty Safeguards (DoLS). Appropriate applications had been made and the conditions of the authorised orders were followed to ensure any restrictions of people’s freedom were kept to a minimum. Staff understood the requirements of the Mental Capacity Act (MCA) and we saw evidence the act had been followed, which helped to ensure people’s rights were protected

People spoke positively about the food on offer and we saw people were given sufficient choice. Staff understood people’s individually nutritional needs in order to provide appropriate support.

People who used the service and their relatives told us that staff were kind and considerate. We observed care and saw staff treated people well. It was evident that staff understood the people they cared for which helped them to provide appropriate care.

A range of activities and social opportunities were on offer which included a regular activities programme run by the activities co-ordinator, trips out and links with the local community. People spoke positively about the activities on offer.

The service had a robust improvement plan in place, and we saw evidence this had helped to achieve a range of improvements to the service over the last few months. A range of audits and other checks on the quality of the service were undertaken to allow the service to continually improve. However, further improvements were required to the quality assurance system to drive improvement in the completion of care records. The service needed to ensure that all improvements were completed and these were sustained over time before we could be assured that the service was well led.

We set out to answer our five questions:

Is the service caring?

Is the service responsive?

Is the service safe?

Is the service effective?

Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, discussions with people using the service, the staff supporting them and looking at records.

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

Safe

We found some improvements were needed to ensure the service was safe.

People told us they felt safe in the home, for example one person told us “the staff do a good job and I feel safe living at Ashcroft.” We found systems were in place to investigate people’s concerns to ensure people were kept safe. Staff had received training in safeguarding and understood how to identify and raise concerns.

However, staffing levels were not sufficient to ensure the safety of people who used the service. A large number of agency staff were used, who did not always have the skills and experience to understand people’s individual needs. This put a strain on permanent staff and meant people sometimes had to wait for care or support.

Effective

We found some improvements were needed to ensure effective care.

Care was not always effective as people had not always had their current needs assessed. Care plans required updating to reflect people’s current needs. Also, for some people there was no evidence that they received some aspects of their care, as documentation was not always completed, for example regular re-positioning to reduce the risk of pressure ulcers.

People told us they had choices with regards to their daily lives and praised the food in the home. We observed the lunchtime meal which showed people were given appropriate support and choice.

Caring

We found the service was caring.

People told us staff were kind and caring. For example one person told us “very nice, staff are very good, they help you,” and another person said “They care for us well.” We observed staff displayed warmth and compassion when caring for people and treated them with dignity and respect.

Responsive

We found some improvements were needed to ensure the service was responsive to people’s needs.

The home was in the process of carrying out care plan reviews. However changes to people’s care identified through care plan reviews were not always implemented, which showed the service was not always responding to people’s needs and requests.

There was evidence that people were referred to healthcare professionals such as district nurses and doctors to ensure the service responded to any health concerns.

We saw a range of activities were available and people reported that these were entertaining and worthwhile.

Well Lead

We found the service was well lead.

The manager had identified the problems we found with care and staffing levels at the home through robust quality assurance systems. They had enlisted a specialist team of staff support to action improvements over the coming months. There was a clear sense of direction and commitment from the management team to ensure these improvements were achieved.

Incidents and complaints were fully investigated and there was evidence that lessons were learnt to ensure continuous improvement.

We spoke with two people who told us they felt safe in the home. We found people were safeguarded from abuse as the provider had arrangements in place to identify and act on allegations of abuse. The staff we spoke with were aware of safeguarding and the correct processes to follow.

We found care records were easy to navigate and contained key information and assessments relevant to each person. The provider had transferred all care records to a new format, which staff said were an improvement as information was easier to find. The provider had appropriate records in place in relation to its staff such as recruitment and training records.

During the inspection we observed care in the communal areas of the home and saw staff generally interact positively with residents, treating them with dignity and respect.

We spoke with three people who used the service who were all happy to live in the home. One person told us “The staff are lovely here and treat me with respect.” Another person told us “Although I would obviously like to live at home I am perfectly happy living at Ashcroft, I have a pleasant and comfortable room and the food is always very good.”

We found people received care and support that met their needs and was delivered by caring and compassionate staff.

However, we found there were not suitable arrangements in place to protect all service users from abuse as some incidents had not been acted on because they had not been reported to management by staff.

We found the home was generally a clean and hygienic environment and the provider had suitable arrangements for infection prevention and control in place.

However, we found due to the way care records were organised, it was very difficult to find information on people’s care, with some information was duplicated or missing. This put people at risk of receiving care or treatment which was unsafe.

We used a number of different methods to help us understand the experiences of people who used the service such as reviewing care records and observing care. This was because some of people who used the service had complex needs which meant they were not able to tell us their experiences

People who were able told us they enjoyed living at Ashcroft and were complementary about the care provided by staff. One person said "I have lived here number of years, I am well looked after and have no concerns about the service or staff. Another said "Although I would prefer to live in my own home I am perfectly happy living at Ashcroft and enjoy the company."

We spoke with three visitors and they told us they were pleased with the standard of care and facilities provided by the service. One person told us their relatives had lived at the home for a number of years and they continued to be satisfied with the care provided and were always made to feel welcome. They described the service overall as "brilliant."

We spoke with one visiting healthcare professional who told us they had no concerns about the care, treatment and support provided by the service. They said staff always followed their advice and guidance.

No comments were obtained from people who use services at this follow up improvement review.

People who use services and their visitors told us that they were being well cared for and overall the staff treated them as individuals. The home was well maintained and clean and people were being cared for with dignity and respect. People said the food is good and they told us that the menu is varied and they are always offered a choice and they also said staff are always willing to offer an alternative if they don’t like what’s on the menu.