We inspected Asher Nursing Home on 6 March 2018. Asher 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. Asher Nursing Home is a mental health nursing home registered to provide care for up to 17 people, with a range of enduring and complex mental health needs. On the day of our inspection there were 17 people living at the service, who required varying levels of support. We previously inspected Asher Nursing Home on 11 January 2017 and found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and further areas of improvement were required. We asked the provider to take action to make improvements and these actions have been completed.

When staff were recruited, their employment history was checked and references obtained. Checks were also undertaken to ensure new staff were safe to work within the care sector. People were cared for in a clean and hygienic environment and appropriate procedures for infection control were in place.

Staff had received essential training and there were opportunities for additional training specific to the needs of the service, such as the treatment of specific infections and palliative care (end of life).

The provider undertook quality assurance reviews to measure and monitor the standard of the service and drive improvement. They had developed a strategic action plan to ensure improvement was sustained.

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

Staff were knowledgeable and trained in safeguarding adults and what action they should take if they suspected abuse was taking place. Staff had a good understanding of equality, diversity and human rights.

Medicines were managed safely and in accordance with current regulations and guidance. There were systems in place to ensure that medicines had been stored, administered, audited and reviewed appropriately.

People were happy and relaxed with staff. They said they felt safe and there were sufficient staff to support them. Staff had received both supervision meetings with their manager, and formal personal development plans, such as annual appraisals were in place.

Risks associated with the environment and equipment had been identified and managed. Emergency procedures were in place in the event of fire and people knew what to do, as did the staff.

People were being supported to make decisions in their best interests. The registered manager and staff had received training in the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). Accidents and incidents were recorded appropriately and steps taken to minimise the risk of similar events happening in the future.

People were encouraged and supported to eat and drink well. There was a varied daily choice of meals and people were able to give feedback and have choice in what they ate and drank. Health care was accessible for people and appointments were made for regular check-ups as needed.

People felt well looked after and supported. We observed friendly relationships had developed between people and staff. Care plans described people’s preferences and needs in relevant areas, including communication, and they were encouraged to be as independent as possible. People’s end of life care was discussed and planned and their wishes had been respected.

People chose how to spend their day and they took part in activities. They enjoyed the activities, which included, bingo, arts and crafts, park walks and themed events

We inspected Asher Nursing Home on the 11 January 2017. We previously carried out a comprehensive inspection at Asher Nursing Home on 10 and 11 December 2015. We found the provider was in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because we identified concerns in relation to the management of medicines, the recording of people’s aspirations and goals, the provision of meaningful activities and quality monitoring. The service received an overall rating of ‘requires improvement’ from the comprehensive inspection on 10 and 11 December 2015. After this inspection, the provider wrote to us to say what they would do to meet the legal requirements in relation to these breaches.

We undertook this unannounced comprehensive inspection to look at all aspects of the service and to check that the provider had followed their action plan, and confirm that the service now met legal requirements. We found improvements had been made in the required areas. However, we identified a further breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to recruitment practices. Additionally, areas of improvement were identified in relation to infection control, staff training and management oversight of the service.

The overall rating for Asher Nursing Home remains as requires improvement. We will review the overall rating of requires improvement at the next comprehensive inspection, where we will look at all aspects of the service and to ensure the improvements have been made and sustained.

Asher Nursing Home is a mental health nursing home and registered to provide accommodation and care, including nursing care for up to 17 people, with a range of enduring and complex mental health needs. On the day of our inspection there were 17 people living at the service, who required varying levels of support.

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

When staff were recruited, their employment history was checked and references obtained. Checks were also undertaken to ensure new staff were safe to work within the care sector. However, we found that for staff who were recruited before 2012, that no DBS (Disclosure and Barring Services) check had taken place. This placed people at potential risk of receiving care from staff that were not safe to work with vulnerable people. This is a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and is an area of practice that needs improvement.

Procedures in relation to infection control were not robust and this has been identified as an area of practice that needs improvement.

Staff had received essential training and there were opportunities for additional training specific to the needs of people, included managing behaviour that may challenge others. However, we saw that several members of staff had not received essential updated ‘refresher’ training in a timely manner. This is an area of practice that needs improvement.

The provider undertook quality assurance reviews to measure and monitor the standard of the service and drive improvement. However, we found issues in relation to management oversight and acting on known concerns. For example, when we raised our concerns with the management of the service in relation to historical DBS checks not taking place, we were told that the management of the service was aware of these issues, but had not acted upon them. Additionally, it was evident that despite having adequate processes and a training matrix in place, essential updated ‘refresher’ training not being made available in timely way. We have identified this as an ar

We carried out an unannounced comprehensive inspection of this service on 30 June and 2 July 2015. After that inspection we received concerns in relation to the management of people’s nutritional and healthcare needs. As a result we undertook a focused inspection to look into those concerns. Many people living at Asher Nursing Home had lived there for many years. Support and input was required to monitor and manage their mental health needs but as people were becoming older, management of people’s healthcare and nursing care needs was required. We spent time looking at whether people’s healthcare needs were effectively managed. This report only covers our findings in relation to those/this topic. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Asher Nursing Home on our website at www.cqc.org.uk.

Based on the evidence we have seen, we have revised the rating for the key question, is the service effective? To’ Inadequate’. This therefore means the overall rating has been revised from ‘Requires Improvement’ to ‘Inadequate’. This means that Asher Nursing Home has been placed into ‘Special measures’ by CQC.

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

Asher Nursing Home is a mental health nursing home providing care and support for people living with enduring and complex mental health needs. The home can accommodate up to 17 people and on the day of the inspection, 17 people were living at the home. The age range of people varied between 35 – 86 years. Predominately people required support with their mental health; support was also needed in relation to diabetes, pressure care and physical disability

Accommodation was provided over three floors with a lift and stairs connecting all floors. Located in Hove, the home provides access to the city centre and seafront. There is good access to public transport. During the course of the inspection, people were seen coming and going, going out to see friends, shopping or meeting family.

A registered manager was not 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 and associated Regulations about how the service is run. An acting manager was in post whilst a registered manager was being recruited.

The management of diabetes required improvement. Nursing staff did not have an oversight of people’s blood sugars, placing people at risk of high and low blood sugars. Where the need for daily blood sugar readings had been identified, this was not being carried out. Care staff identified that care plans failed to provide sufficient guidance on how to manage people’s diabetes.

Care plans also failed to recognise the interaction between people’s healthcare needs and mental health needs. Where people were living with diabetes, staff members felt there was not sufficient guidance on how to effectively manage their diabetes when their mental health needs were prevalent.

Mechanisms were not consistently in place for assessing people’s nutritional needs. Consideration had not been given to providing fortified diets and promoting people’s nutritional intake. Where people were struggling to eat, staff had not considered adapted cutlery or whether the person was having trouble swallowing. For people who required a soft diet, guidance was not in place to assess any potential choking risks and how to ensure their nutritional needs were met whilst on a soft diet. Where people had lost weight, documentation failed to reflect what action if any had been taken and if concerns had been escalated.

People had mixed opinions about the quality and variety of food. One person told us, “The meals were ok I guess but they give me what I want, the portions can be a bit small.” Another person told us, “It’s rubbish.” Staff members also felt improvements could be made to the quality of food. One staff member told us, “People need more fresh vegetables.”

Staff were dedicated to ensuring the lunchtime meal met people’s preferences. A wide variety of meal options were provided and people ate at various times in accordance to their individual lifestyles. Staff members ate alongside people promoting the lunchtime experience to be a social event. With compassion, staff members spoke about the people they supported. Staff members had a firm understanding of people’s individual needs, personality traits and how best to support people.

We found a breach 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 carried out a responsive inspection at Asher Nursing Home to follow up on non-compliance, regarding staff training, supervision and appraisals, identified at the previous inspection on 13 June 2014.

We spoke with the registered manager, the deputy manager and two members of staff. We also looked at relevant documentation, including training records, supervision and appraisal schedules.

The manager told us that since the last inspection, staff training had been reviewed, with the area manager, to ensure that all mandatory (essential) training was up to date. This was supported by the training matrix that we were shown. We found that appraisals had been reinstated and all staff had received formal supervision, which was now being provided on a regular basis.

One member of staff told us “It’s definitely improved. We get lots of support, which is important because it can be challenging and get very stressful here."

Our inspection team was made up of one adult social care inspector and an expert by experience. We answered our five questions: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

The service had a manager in post. We saw evidence that the manager was in the process of applying for registration with the Care Quality Commission.

We spoke with eight people who used the service. During the inspection, we spoke with the manager, a registered nurse, the chef and three care staff.

Below is a summary of what we found. The summary describes what people who used the service and the staff told us, what we observed and the records we looked at. If you want to see the evidence supporting our summary please read the full report.

Is it safe?

People told us that they felt safe in the care of Asher Nursing Home.

People were safeguarded from the risk of abuse or harm.

Staff demonstrated a sound understanding of safeguarding vulnerable adults and knew how to report any concerns of abuse or harm.

People could freely access the local community and could come and go from the service as they pleased.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Deprivation of Liberty Safeguards. We found the location to be meeting the requirements of the Deprivation of Liberty Safeguards (DoLS).

Systems were in place for staff to learn from incidents, accidents and near misses

Is it effective?

People had their needs assessed and individual care plans were devised. Before anyone joined the service, a pre-admission assessment took place.

Care plans were detailed and provided personalised information which enabled care staff to provide care and treatment which was individual to that person.

People maintained good health. The service worked closely with GPs, care coordinators and the local authority.

Systems were in place to monitor, assess and improve the quality of the service. Feedback was regularly obtained from people who used the service and their relatives.

Complaints were handled and resolved appropriately.

We found that people were provided with appropriate nutrition and had a choice in relation to the food options available. The service offered a variety and range of meal options. A menu was displayed and people had access to hot and cold drinks throughout the day. People spoke positively of the food provided.

Is it caring?

People spoke positively of the care provided.

Staff demonstrated a good understanding of the care needs of people who used the service.

People were encouraged to treat the service as their own home.

People were treated with dignity and respect.

Staff spoke with fondness about the people they supported.

Is it responsive?

People had their needs assessed and support was sought where necessary.

Where's people's health had rapidly deteriorated we saw that the service took appropriate action.

People had access to activities. We received mixed comments from people about the opportunities of social stimulation and activities.

Is it well-led?

Throughout our inspection, staff spoke positively about the culture of the service and told us it was well-managed and well-led.

Staff we spoke with had a clear understanding of why they were there and what their roles and responsibilities were.

The service had a business continuity policy in place. This made sure that each service had a plan in place to deal with foreseeable emergencies. This would reduce the risk of people's care being affected in the event of an emergency such as flooding or a fire.

Supervisions and appraisals were not regularly provided to care staff to enable professional development.

Training records demonstrated that staff did not receive up to date training when required.

We carried out a responsive inspection at Asher Nursing Home following receipt of concerning information about the standard of cleanliness and infection control.

We spoke with the acting manager and two members of staff. We observed staff interacting with people who used the service. We found that staff used protective personal equipment (PPE) appropriately.

There were effective systems in place to reduce the risk and spread of infection.

Staff were trained in infection control and staff we spoke with confirmed they have regular training in infection control. One staff member told us, “We’ve made great progress with cleanliness especially as this is a mental health home and often we work with people who have previously self-neglected or been homeless.”

There were 17 people who used the service at the time of our inspection. We used a number of different methods to help us understand the views and experiences of these people, as not all of them were able to tell of their experiences.

We observed the care provided and looked at supporting documentation. We spoke to four members of staff, the deputy manager and the area manager. We talked briefly with people who used the service.

We found there had been an improvement in the overall level of care and support that people received. Records showed that people's care needs had been assessed, planned, reviewed and delivered in line with their individual care plan.

Staff were well trained and demonstrated a good knowledge of people's needs. Recruitment procedures were robust and staffing levels had been improved and were sufficient for the needs of those who used the service.

The overall level of staff support, supervision and morale had improved. This provided them with the necessary back up to carry out their role and to meet people’s needs.

There were better systems in place to identify, assess and manage risks to people who used the service.

People who used the service were able to contribute to decision making and their views were taken into account.

During our inspection we spoke with three people who used the service. We also spoke with five staff members; these were the registered manager, the deputy manager, two care workers and the chef.

The people we spoke with told us they were generally happy with the care they had received and with the staff team.

Staff we spoke with said that they had undertaken safeguarding vulnerable adults training, and people we spoke with told us that they felt safe and knew who to talk to if they had any concerns.

Staff we observed had an understanding of the support needs of people who used the service. However we found that some of the documentation used for care planning had not been reviewed regularly to ensure that the information detailing the care to be delivered had been up to date.

During our inspection, staff we spoke with confirmed that they had received relevant training, but told us that they had not always felt supported by the service to carry out their roles effectively. We looked at staffing rotas and during our inspection observed levels of staffing. We saw that the service did not have enough qualified, skilled and experienced staff to meet people’s needs at all times.

The service had quality assurance systems in place to monitor the quality of the service provided and to gain the views of the people who used the service, but at the time of our inspection, some of these systems had not been used for some time, or were not being used at all.

We inspected Asher Nursing Home on the 10 and 11 December 2015. Asher Nursing Home is a mental health nursing home providing care and support for people living with enduring and complex mental health needs. The home can accommodate up to 17 people. On both days of the inspection, 15 people were living at the home. The age range of people varied between 35 – 86 years. Predominately people required support with their mental health; support was also needed in relation to diabetes, pressure care and physical disability.

At our last two inspections in June and July 2015, breaches of legal requirements were found and we took enforcement action against the provider. We issued warning notices in relation to person centred care, safe care and treatment and good governance. Requirement actions were served in relation to need for consent, safeguarding service users from abuse and improper treatment and nutritional needs. The provider wrote to us to say what they would do to meet legal requirements of the Health and Social Care Act 2008 (Regulated Activities) 2014. After our last inspection in July 2015, Asher Nursing Home was placed into special measures. This inspection found that there was enough improvement to take the provider out of special measures.

We undertook this unannounced comprehensive inspection to check that they had followed their action plan and to confirm that they now met legal requirements. We found improvements had been made with some areas. However there remain some areas that are yet to be fully addressed and some new concerns relating to the management of medicines.

Accommodation was provided over three floors with a lift and stairs connecting all floors. Located in Hove, the home provides access to the city centre and seafront. There is good access to public transport. During the course of the inspection, people were seen coming and going, going out to see friends, shopping, meeting family, having family visit or going out in local taxi’s.

A registered manager was not in post. A manager was in post, who was not yet registered with the Care Quality Commission. 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 received their medicines on time and medicines were stored in line with legal requirements. However, new concerns were identified in relation to the management of as required’ (PRN) medicines which placed people at risk of them not receiving their medicines in accordance with the prescribed guidance.

An activity timetable was now in place but further work was required to ensure people received meaningful activities and the risk of social isolation was minimised. One person told us, “All I do is drink tea and smoke. That isn’t an existence; I might as well be dead. There are no activities here.” We have therefore identified this as an area of practice that requires improvement.

Care plans and risk assessments had been reviewed and updated to provide robust guidance for staff to follow. Care plans also now included information on the person’s life history and were written from the perspective of the person. However, care plans continued to lack guidance on how to support people to meet their individual goals, what their aspirations were or how to build on their strengths. It was not always clear what the person’s goal was and if staff were engaging with the person to promote their independence and support them to move on.

Slight improvements to the home’s quality assurance framework had been made; however, the provider lacked oversight of incidents and accidents. Incidents and accidents were not monitored for any emerging trends, themes or patterns. We have identified this as an area of practice that requires improvement.

People and staff commented that the variety and quality of food had improved. One staff member told us, “The variety of food is better, more vegetables and people are trying to eat more vitamins.” Although improvements to the quality of food had been made, the management team and staff lacked oversight of people’s weight. Various recording systems made it hard for management to strategic oversight of people’s weights and monitor for any weight loss or weight gain. Guidance documented in people’s nutritional care plans were not consistently embedded into practice. We have identified this as an area of practice that needs improvement.

Further work was required to ensure people’s nursing care needs were effectively met. Staff recognised that Asher Nursing Home was a nursing home and therefore they should be providing nursing care, however, staff lacked an understanding of basic nursing care, such as ensuring the setting of people’s air flow mattresses were correct. We have identified this as an area of practice that needs improvement.

Mental capacity assessments were now completed in line with legal requirements. Consideration had been given to whether people were deprived of their liberty under the Deprivation of Liberty Safeguards (DoLS). Where restrictive practice was taking place, clear documentation was in place.

Staff spoke highly of the changes made since the last two inspections and of the new manager. One staff member told us, “There’s improvement to staff morale and the new manager appears to be very good. She took time to speak with staff one to one to see whether we felt supported and what could be done which was great.”

We found three reaches 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.