The inspection took place on 26 June and 3 July 2018. The first day of inspection was unannounced and the second day announced. When we last inspected the home, we found the provider had breached the regulations relating to person centred care, safeguarding people from abuse and good governance. This was because some night staff raised concerns about a lack of personalised care for people, such as an expectation that people living with dementia had to be up and dressed early. Some night staff raised allegations of a safeguarding nature in the past that hadn’t been dealt with. Other staff felt they weren’t able to raise concerns openly. We also found the quality assurance processes in the home had not been effective in dealing with these matters. We rated the home as Requires Improvement.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions is the service safe, effective, caring, responsive and well-led to at least good. We found progress had been made and the provider was now meeting these regulations.

However, we also found the provider had breached a further regulation relating to safe care and treatment. Care plans were out of date and no longer reflected people’s needs. In some cases, the required care plans were not in place. This meant staff did not have access to the guidance they needed to ensure people received care that met their needs and kept them safe.

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

Care plans were often not personalised or written in a dignified manner. Care plan evaluations lacked meaningful information and were repetitive. We have made a recommendation about this.

Ashfield Court 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. Ashfield Court accommodates up to 46 people across two separate units, each of which have separate adapted facilities. At the time of our inspection there were 46 people living at the home some of whom were living with dementia.

The home had a registered manager. 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, relatives and staff gave us good feedback about the registered manager and their management of the home.

The provider’s systems for monitoring the quality of care plans and other care records had not been effective in identifying and dealing with the issues we found. Records confirming the care people had received from staff were not completed accurately. This included records where people required regular positional changes to protect their skin and to monitor their food and fluid intake.

People and relatives gave us positive feedback about the care provided and the kindness of the staff team. Throughout our visits we observed caring interactions between people and staff.

People, relatives and staff told us the service was safe. Staff had a good understanding of safeguarding and the provider’s whistle blowing procedure. Staff said they had no concerns about people’s safety but knew how to raise concerns if needed.

There were enough staff on duty to assist people in a timely way. Staff confirmed told us staffing levels were sufficient and there was a visible staff presence around the home when we visited. The provider had effective recruitment checks to ensure only suitable staff worked at the home, such as Disclosure and Barring Service (DBS) checks and requesting references.

As with our last inspection me

The inspection took place on 1 and 9 March 2017 and was unannounced.

We last carried out a comprehensive inspection of this service in November 2015 where we found the provider was not meeting the regulations relating to safe care and treatment, good governance and staffing. In addition, the provider had not sent us notifications which they are legally required to do as part of their registration. We undertook a focused inspection on 14 June 2016 and found that improvements had been made and they were now meeting legal requirements. We did not change the home’s overall rating at the focused inspection because to do so requires consistent good practice over time.

Ashfield Court provides residential care for up to 46 people, some of whom are living with dementia. Accommodation was spread over two floors. People who were living with dementia lived on first floor. At the time of our inspection there were 44 people living at 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.

The registered manager was currently overseeing the management of one of the provider’s nearby nursing homes. He explained that there was the possibility of him becoming manager at this nursing home. As a result, an ‘interim manager’ had been appointed who the registered manager explained would eventually take over his role as manager at Ashfield Court and would register with CQC. She had worked at the service for a number of years. We were supported by both the registered manager and interim manager on both days of the inspection.

On the first day of our inspection, we spoke with people, relatives and day staff who were positive about the home. Following our first visit, we spoke with night staff so we could ascertain how care and support was delivered at night. Certain night staff said that day staff expected them to get most people with a dementia related condition up and dressed in the morning. As a result of this information we carried out another visit to the home at 7.30am.

On the second day of the inspection, we found that most people who lived in the unit for people with a dementia related condition were up and dressed by 7.30am. We spoke with staff who told us they had woken some people at 5am to get them up and dressed.

There were safeguarding and whistleblowing procedures in place. Day staff told us that they had no safeguarding concerns. Certain night staff however, raised several safeguarding allegations. Some night staff told us that they had raised concerns in the past about specific staff and care practices; however no action had been taken. Other staff told us that they had not felt able to raise specific concerns. We passed their concerns to the local authority’s safeguarding team, the registered manager and members of the provider’s senior management team to investigate.

Checks and tests had been carried out to ensure that the premises were safe. An electronic medicines system was used to manage medicines. We found there was a safe and effective system in place for the receipt, storage, administration and disposal of medicines.

Recruitment checks were carried out to ensure that staff were suitable to work with vulnerable people. We checked staff rotas and noted that staffing levels were not always maintained at the numbers advised by the manager. He told us that due to last minute sickness, it was not always possible to get staffing cover. He said they were over recruiting to help ensure they could cover all shifts at the home. We have made a recommendation about this.

Records demonstrated that most staff had completed training in safe working practices and to meet the specific needs of p

We last inspected the service on the 18 and 20 November 2015 when we found the provider was not meeting Regulations 12, 17 and 18 of the Health and Social Care Act (Regulated Activities) Regulations 2014 and related to safe care and treatment, good governance and staffing.

Following our inspection in November 2015, the provider sent us an action plan to show us how they would address our concerns and that they would be addressed fully by the 30 April 2016.

At the inspection in November 2015 the provider had also not sent us notifications which they are legally required to do as part of their registration. We dealt with this matter by issuing a fixed penalty notice to both the provider and the registered manager which they accepted and paid.

We undertook this focused inspection on 14 June 2016 to check that the provider had followed their plan and to confirm they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Ashfield Court on our website at www.cqc.org.uk

We could not improve the rating for safe or well led from requires improvement because to do so requires consistent good practice over time. We will check these again during our next planned comprehensive inspection.

Ashfield Court provides residential care for up to 46 people, some of whom are living with dementia. At the time of our inspection there were 43 people living at the service including one person who had just been taken into hospital.

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.

We found that staff levels overnight and daytime shifts were adequate and the provider had increased the number of staff on duty to safely provide care to the people they supported. Staff we spoke with said that they could manage workloads much better now.

The people we spoke with felt safe living at the home and the relatives we spoke with confirmed their views.

Accidents were recorded, monitored and analysed by the registered manager who was fully aware of all accidents that had occurred within the service.

Staff at the service followed safe management of medicines best practice. ‘As required’ medicines were now detailed fully and medicines risk assessments were in place were required. Training in medicines management had been completed and staff had undertaken competency checks to ensure they followed best practice.

We saw very little in the way of activities taking place on the dementia unit and the registered manager said they would look into this. We will follow this up at our next full rated inspection.

We found that there was now a robust range of quality assurance checks in place which were completed by the registered manager, staff and representatives of the provider. These covered areas in connection with health and safety, medicines, care planning, and infection control. The registered manager also had in place a process for monitoring that notifications to the Commission had been sent.

People’s care records and other documents related to their care were now stored in secure locked cabinets, with keys held separately and monitored by administration staff.

At the time of the inspection there were 36 people living at the home. Due to their health conditions and needs not all people we spoke with were able to share their views about the service they received. During our visit we spoke with six people who used the service and observed their experiences. We spoke with the registered manager, six members of staff and two visiting relatives.

We considered all the evidence we had gathered under the regulations we inspected. We used the information to answer the five questions we always ask;

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well led?

This is a summary of what we have found.

Is the service safe?

The provider had effective systems in place to identify, assess and manage risks to the health, safety and welfare of people who used the service and others. We saw risk assessments had been completed for people who were assessed as being at risk of falls.

We saw people were safe and protected from abuse. Staff demonstrated to us an understanding of the types of possible abuse and how they should be reported. All staff had received training in the safeguarding of vulnerable adults and whistleblowing.

We spoke to people who used the service and asked them if they felt safe there. Comments included, "I have never had any problems. No one comes into my room without my permission" and "I have never had anything taken. It is perfectly safe here." People told us they new how to report any incidents. One person said, "I know how to complain. I would just speak to the manager."

The Care Quality Commission monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We saw policies and procedures were in place and the manager and deputy manager had received training in the Mental Capacity Act 2005 (MCA) and DoLS.

Is the service effective?

We saw staff were supported in their role and received the required training. Staff received regular supervision and were supported to develop professionally.

We spoke to staff about the support they received and the training available. Comments included, “I am supported in my job by the manager” and “The training is good and there is plenty of it.” This meant staff had the opportunity to discuss their concerns with the provider.

Is the service caring?

People were supported and their care was planned and delivered in line with their care plans. We spoke to people who used the service and asked them about the quality of care they received. Comments included, "I am involved in my care plan. I read it and the girls (staff) are lovely to me" and "I am well looked after. I get a bath when I want and the food is very nice." A visiting relative said, " X is very happy at Ashfield. She is well looked after."

People's preferences, interests and needs were recorded in people’s care records. Staff were able to give examples of these when we spoke to them and displayed a good knowledge of the people living at the home and what their needs were.

Is the service responsive?

There was an effective system in place to record and monitor complaints. Complaints were taken seriously and responded to appropriately.

We saw evidence that care staff identified changes in people's needs and acted to make sure they received the care they needed. For example, there was evidence that where one person's health had declined an immediate referral was made to the correct medical professional for advice and support.

Is the service well led?

We saw the manager at the service was registered with the Commission in line with the requirements of the registration of this service and location.

The service had a quality assurance system in place that included the use of surveys from people who used the service, to obtain their opinion.

Two people we spoke with told us that they were happy with the support they received with their medication. One said “ I need to have my eye drops four times a day and I always get them.” We spoke with a relative of a person living in the home who said that they had no concerns about the care provided.

Overall, we found that medicines were handled safely.

We found there was sufficient bathing equipment available in order to ensure the safety of people, promote their independence, comfort and meet their assessed needs.

Some people using the service had complex needs which meant they were not able to tell us their experiences. We spoke with six people who used the service and three visitors. People told us they could choose how to spend their time and could get up and go to bed whenever they wanted. They said the staff were very caring and were always willing to help. They felt their privacy and dignity were respected. Comments included, "They knock on the door before coming into my room, but I usually like to have my door open", "I think the staff are terrific", "I'm happy here and enjoy the meals", "It's fine, I get what I like to eat and I enjoy the bingo", "I like my bedroom and like to watch my TV or listen to music" and "The staff are lovely, very nice people". Three visitors said they were confident their relatives were well looked after. Comments included, "There's nothing to worry about here, they're well looked after", and "The staff are great and nothing is a bother".

Systems were in place to ensure appropriate staff were recruited to care for people who used the service. There were sufficient staff on duty to care for the people who used the service and they were well trained and supported to carry out their roles.

The provider had taken reasonable steps to identify possible abuse and prevent it from happening.

There were effective systems in place to assess and monitor the quality of service that people received.

We spoke with six people and three relatives to find out their opinions of the service. One person told us, “There’s nothing to fear when you come here.” A relative told us, “I think the words ‘kind’ and ‘cheerful’ sums up Ashfield Court.”

People and relatives told us that consent was gained before care was carried out. One person said, “They always ask me, they never force me to do anything.”

People and relatives were complimentary about the service and the care and support provided. One person told us, “They look after us great here. There are things going on all the time.” We considered that people experienced care, treatment and support that met their needs.

People told us that they liked a bath or a shower. However, we noted that the home did not have any separate shower units. There were two bathrooms on the ground floor and three bathrooms on the first floor, but only two baths were fitted with the hoisting equipment which was needed to assist people in and out of the water. We concluded that bathing equipment was not available in sufficient quantities in order to meet people’s needs, ensure their safety and promote their independence and comfort.

We found that people were cared for by staff who were supported to deliver care safely and to an appropriate standard.

People and relatives said they felt able to raise any concerns to management and make comments about the service. Records confirmed that people were made aware of the complaints system.

This unannounced inspection took place on 18 and 20 November 2015. We last inspected in September 2014 and found the service was meeting all the regulations that we inspected at that time.

Ashfield Court provides residential care for up to 46 people, some of whom are living with dementia. At the time of our inspection there were 44 people living at the service including one person in hospital.

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.

The provider did not always have enough staff on duty to meet the needs of people living at the service. People told us that sometimes they felt there was not enough staff and our second day of inspection confirmed this when we found night shift staffing levels lacking. There were safe recruitment procedures in place and staff were checked prior to starting work to ensure they were suitable for their role and safe to work with vulnerable people. Staff told us they were well supported and received suitable training to allow them to complete their work safely. They told us they could ask the registered manager if they wanted to go on particular training to enhance their skills and this was arranged.

Accidents were recorded and monitored by the registered manager, although the registered manager was not always aware of the full details of all falls.

Medicines were not always managed safely and we found some shortfalls, including with the information available for ‘as required’ medicines and medicines risk assessments that were not in place.

Staff were aware of their safeguarding responsibilities and told us they would report anything of concern.

Regular checks were made on the premises and the equipment used within. The registered manager ensured that emergency contingency plans were in place in case of emergencies like flooding or fire.

The Care Quality Commission (CQC) is required by law to monitor the operations of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS), and to report on what we find. MCA is a law that protects and supports people who do not have the ability to make their own decisions and to ensure decisions are made in their ‘best interests’. It also ensures unlawful restrictions are not placed on people in care homes and hospitals. In England, the local authority authorises applications to deprive people of their liberty. We found the provider was complying with their legal requirements.

People told us they enjoyed the food prepared for them. We found people received a range of nutritious meals and refreshments to meet their dietary needs throughout the day. Staff supported people who needed help with eating and drinking appropriately.

Arrangements were made for people to see their GP and other healthcare professionals when they needed to do so. People had been referred for specialist support if that was required, for example, to the speech and language team.

People were respected and treated with dignity, compassion, warmth and kindness. People and their relatives we spoke with highlighted the quality of care provided by staff at the service.

People had their needs assessed and care plans with supportive risk assessments were put in place and reviewed regularly. However, we found that some sections of people’s records were not always completed fully and were not always stored securely.

People were involved in a range of stimulating activities inside and outside of the service and chose what they wanted to participate in.

Information on how to make a complaint was available to people at the service and to relatives and visitors alike. Records showed that complaints had been dealt with effectively.

People were encouraged to make their views known and the service supported this by holding meetings for people and their relatives and completing surveys.

Audits and checks were completed by staff, the registered manager and the provider. These covered a range of areas, including, infection control, health and safety and medicines. We found that these checks had not uncovered the shortfalls we had identified during our inspection. Including those related to medicines, records and notifications (which the provider is legally obliged to send us).

We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to the management of medicines, staffing and good governance. You can see what action we told the provider to take at the back of the full version of this report.

The provider had not submitted statutory notifications as legally required regarding, for example Deprivation of Liberty Safeguards authorisations, incidents where the police had been involved and safeguarding incidents. We are pursuing this matter with the provider and the registered manager and we will report on our action when it is complete.