About the service: Ashfield Lodge is a residential care home that was providing personal and nursing care to 20 people living with dementia at the time of the inspection.

People’s experience of using this service:

People living at the home and their relatives were happy with the standard of care they received. They felt that people’s needs were met and that staff skills supported them to provide kind and compassionate care. There were enough staff to support people’s care needs and to monitor people to ensure their safety.

People had been involved in planning their care and were confident to raise any issues they had with the registered manager. Care plans were well written and regularly reviewed. People were supported to be pain free at the end of their lives.

People’s ability to make decisions had been assessed and where needed applications for Deprivation of Liberty Safeguards had been correctly submitted. People were offered choices in their everyday lives.

Risks to people had been identified and care was planned to keep people safe. Risks around eating safely and maintaining a healthy weight were identified and where necessary people were referred to healthcare professionals for advice. Medicines were safely managed. Staff had received training in infection control and knew how to work to minimise the risk of infection.

People were supported emotionally and physically with activities which included pamper sessions and walks along the river.

Systems to monitor the quality and safety of the service were effective. The registered manager took corrective action to resolve any concerns identified. Incidents and complaints were analysed and learning was shared with staff. People living at the home and their relatives were encouraged to raise issues around quality and safety at regular residents’ meetings.

Rating at last inspection:

At the last inspection the service was rated as Requires Improvement (report published 22 September 2017). At this inspection we found the provider and registered manager had made the necessary improvements.

Why we inspected:

This was a planned inspection based on the previous rating.

Follow up:

We will continue to monitor intelligence we receive about this service until we return to visit as per our inspection programme. If any concerning information is received, we may inspect sooner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

The inspection took place on 7 and 8 November 2017 and was unannounced.

Ashfield Lodge 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 Lodge accommodates 20 people who require nursing care in a purpose build single story building. Most of the people living at Ashfield Lodge were living with dementia. There were 20 people living at the home on the day 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.

This is the third consecutive time the service has been rated Requires Improvement.

At the last inspection we found the provider was in breach of regulations 9, 11,12,14,17 and 18. We found that the provider had not always engaged people in developing their care so care was not meeting their needs. Consent was not always gained by staff before providing care and people’s rights under the mental capacity act were not respected. Medicines were not properly managed and risks to people were not always identified. People did not receive adequate support in relation to food and drink. Staffing levels did not support safe care and staff did not receive adequate training and support. The systems to monitor the quality of care provided were not effective at identifying and rectifying concerns.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve all the key questions to at least good.

At this inspection we found the manager had made improvements in all but one of the areas where we had concerns. The management of medicines was still not adequate to ensure people’s medicines were stored safely and available when needed. You can see what action we have told the provider to take at the back of the full version of this report.

Audits to identify areas for concern or improvement were effective in most areas but had failed to identify the issues with medicines management. The environment was in need of decoration and did not support people living with dementia to be independent and there was an unpleasant odour of urine in the home. People were not supported to manage their continence which impacted on their privacy and dignity.

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.

Staff were kind and caring and were enough staff to meet people’s needs. Staff were provided with appropriate training and support which reflected current guidance and legislation. Staff worked well together and received appropriate management so that they understood their roles and responsibilities. Regular quality meetings supported the registered manager to continually drive improvements in the home and to implement changes to reflect best practice. Recruitment processes ensured staff were safe to work with people living at the home.

Risks to people were identified and action was taken to keep people safe. Incidents were reported and action was taken to reduce the risk of the same incident reoccurring. Incidents were monitored at the home and at provider level to ensure lessons learnt in all the provider’s homes were shared to keep people safe. Staff knew how to keep people safe from the risk of infection, however there was an unpleasant odour in the parts of the home.

People were offered choices about their everyday lives. They were supported to access a choice of food and drink which they were able to consume safely and with appr

The inspection took place on 30 January 2017 and was unannounced.

The home is in a purpose built building all on one level. The home is registered to provide accommodation with nursing care for a maximum of 20 older people or people living with dementia. There were 15 people living at the home when we inspected all of whom required nursing care. There was also a day care centre attached to the home but this was staffed separately.

There was a registered manager for the home. 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.

However, on the day we inspected the registered manager was not available. The operations manager told us that the registered manager would not be returning to work as they had not effectively managed the home. Following our inspection the registered manager contacted us and told us that they had appointed a new manager and deputy manager for the home.

The provider was not meeting the legal requirements in multiple areas of the home. They had failed to take action to ensure that people’s rights were fully protected under the Mental Capacity Act (2005). They had failed to ensure there were enough staff available to meet people’s needs in a timely way and that the staff received appropriate training and support to help them develop the skills needed to provide safe care. We found that care was not always planned to reduce the risks people faced and that the guidance for the administration of medicines prescribed to be taken as required was not always adequate to ensure consistent care was offered. People did not receive the support they required to ensure they received enough to eat and drink. The care provided did not meet people’s individual needs or ensure that they were calm and settled and able to live full lives.

The provider had failed to improve the quality of care since our last inspection and to effectively monitor the quality of care people received. They had not taken successful action when concerns were raised about the registered manager’s abilities to stop people experiencing a decline in the standard of care they received. You can see what action we have told the provider to take at the back of the full version of this report.

Staff knew how to keep people safe from abuse and knew how to raise concerns both within the organisation and with external agencies. Appropriate checks had been completed to ensure staff were safe to work with people living at the home. However, the use of agency staff meant that people did not receive care from people they knew and trusted.

Staff provided care that was task focused and at did not always put people at the centre of the care provided. Where people had communication difficulties they were not always offered choices of asked for their opinion on the care they received. People were not always supported to manage their appearance in the way they had done before moving into the home. Activities were not fully utilised to keep people calm and settled and to lead a fulfilled life.

This inspection took place on 14 December 2015 and was unannounced.

The home is in a purpose built building all on one level. The home is registered to provide accommodation with nursing care for a maximum of 20 older people or people living with a dementia. There were 20 people living at the home when we inspected all of whom required nursing care. There was also a day care centre attached to the home but this was staffed separately.

At the time of our inspection there was a manager in post who had applied to become 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.

The Care Quality Commission is required by law to monitor how a provider applies the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are in place to protect people where they do not have capacity to make decisions and where it is considered necessary to restrict their freedom in some way. This is usually to protect themselves. People’s abilities to make decisions were assessed and where necessary DoLS authorisations were in place. However, conditions applied to DoLS were not always included in people’s care plans.

Staff were kind and caring and spoke with people in a way which respected their privacy and dignity. There were good relationships between people and their care staff and these were supported to grow with people able to have their preferred care worker give care.

People received care from a staff team which was supported to develop and maintain the skills needed to provide safe care through on going training. The provider had a set staffing level, but at times they were unable to ensure that the home was staffed to these levels due to staffing shortages. Staff on shift worked to ensure people’s needs were fully met.

The provider completed appropriate checks to ensure staff were safe to work with people living at the home. Other risks to people while receiving care were also identified and care was planned to ensure that people were safe. However, where people had experienced harm it was not always clear what action had been taken to keep them safe in the future.

People were supported to maintain a healthy weight and to stay hydrated. They were offered a choice of food and appropriate adaptive equipment was available when needed.

People’s care plans accurately recorded the care they needed and staff also knew people’s needs. Care was provided in a person centred way to meet those needs and people were supported to maintain hobbies and activities they enjoyed. People were supported to access healthcare when a need was identified.

Staff told us that the deputy manager was supportive and available to them. However, the manager was not supportive and did not always take appropriate action when issues were raised with them. In addition, we saw the manager had failed to tell us about a number of incidents they were by law required to disclose to us.

We used a number of different methods to help us reach a judgement on the quality of service provision. These included talking with three people who used the service and one visitor to the home. We also spoke with the acting manager, two nurses, two care staff and the cook.

We looked at records. These included care plans and information about how the service was managed. We conducted a tour of the building and observed the interactions between the care staff and people residing at the home.

Records we looked at showed that people’s needs had been assessed and appropriate support provided to care for their needs.

We found that people were provided with a choice of suitable and nutritious food and drink in sufficient quantities to meet their individual needs and preferences. A visitor to the home told us, “The food always looks nice and smells appetising.”

We saw that the building was well furnished and in excellent decorative condition. It was light, airy and spacious and was free of any unpleasant odours.

Records that we saw were accurate, had been regularly updated and were held securely.

We saw that the service was well led and managed.

We used a number of different methods to help us understand the experiences of people using the service, because the people using the service had complex needs which meant they were not always able to tell us their experiences. These methods included observation and speaking to relatives of people using the service.

One realtive said, “Wonderful. We’ve been around a few homes. This is the best we’ve seen. The staff are brilliant.”

Another told us, “The level of care demonstrated at Ashfield is exceptional in my view.”