Ashfield 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. The service is registered to provide care and support to older people with dementia or mental health needs. On the day of inspection there were 36 people living there.

The inspection visit took place on the 4 October 2018. It was unannounced and was planned as a focused inspection, in response to concerns that had been raised with us since the last comprehensive inspection in July 2018. After that inspection we received concerns in relation to staffing levels, unsafe care, poor management and the impact on people using the service. As a result, we undertook a focused inspection to look at safe and well led. This report only covers our findings in relation to those areas. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Ashfield Nursing Home on our website at www.cqc.org.uk.

At this inspection we found continued breaches of Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014; plus, a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. 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.

The team inspected the service against two of the five questions we ask about services: is the service safe and is the service well led. This is because we were concerned the service was not meeting some legal requirements. No risks, concerns or significant improvement were identified in the remaining Key Questions through our ongoing monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

Since the last inspection, there had not been sufficient improvement in the overall governance of the service. The management of medicines, infection control and staffing had continued to deteriorate and the service is now rated inadequate and means the service is 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 enough improvement is not made within this timeframe and 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 and 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.

On the day of inspection there was no registered manage

The inspection took place on 24 and 26 July 2018, and the first day was unannounced. Ashfield 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. Nursing care is provided at this service.

Accommodation for up to 40 people is provided over two floors in two separate units. There were 39 people using the service at the time of our inspection. Ashfield Nursing Home is designed to meet the needs of older people living with or without dementia.

The service had a registered manager at the time of our inspection visit. 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 not available during our inspection visit.

The first day of our inspection visit was unannounced. Ashfield Nursing Home was last inspected in May 2017 and was rated as Requires Improvement. We found breaches of Regulation 17 and Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider did not have effective systems to regularly assess and monitor the quality of care provided to people. Staff had not received training, support and supervision to enable them to carry out the duties they were employed to perform.

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 question(s) Effective and Well-Led to at least Good. On this inspection, we found improvements had not been made. This is the second consecutive time the service has been rated Requires Improvement.

People were not always kept safe from the risk of acquiring infections. People’s medicines were not always managed safely. There was no comprehensive system to enable the provider to review accidents and incidents. There were times when there were not enough staff to meet people’s needs in a timely way. The provider had not taken steps to ensure the environment was suitable for people's needs. People were not given support to access community dental services, but were supported access other healthcare services when required.

People who needed support to communicate were not always able to meaningfully participate in making decisions about their care. People and relatives were not consistently supported to participate in planning or reviewing their care. The provider could not ensure that people, relatives and staff could meet in private, and there was a risk information about people’s care would not remain confidential. Concerns and complaints were not clearly resolved, and the provider did not have clear information about areas where improvements were needed.

The provider had not ensured their quality assurance system was effective in identifying issues and ensuring action was taken to improve the quality of care. The provider did not always respond to feedback from internal audits and external professionals to address areas where the quality of care was poor. The provider had not always notified CQC of significant events as they are legally required to do.

People were kept safe from the risk of abuse. The provider had ensured staff were of good character and were fit to carry out their work. Risks relating to people’s assessed needs had been assessed and mitigated. People received their personal and nursing care from staff who had training to enable them to meet people’s needs effectively. People were supported and encouraged to have a varied diet that gave them sufficient to eat and drink.

People were supported to have maximum choice and control of their lives and

This inspection took place on 16 and 17 May 2017 and was unannounced.

The provider is registered to provide accommodation for up to 40 older people living with or without dementia in the home over two floors. There were 35 people using the service at the time of our inspection. The home provides nursing care.

A registered manager was in post; however, they were no longer working at the service and had submitted an application to cancel their registration for the service. The service was being managed by two managers from other homes owned by the provider. Both managers were present on the first day of inspection and one of the managers was also present on the second day of the inspection. We were told that the new manager would be appointed shortly and they would apply to be registered for this service when 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.

Safe medicines and infection control practices were not always followed by staff.

Staff knew how to keep people safe and understood their responsibility to protect people from the risk of abuse. Risks were managed so that people were protected from avoidable harm and not unnecessarily restricted. Sufficient staff were on duty to meet people’s needs and staff were recruited through safe recruitment practices.

Staff did not receive appropriate training and appraisal. Supervisions were not taking place for all staff. People’s needs were not fully met by the adaptation, design and decoration of the service.

People’s rights were protected under the Mental Capacity Act 2005. People received sufficient to eat and drink. External professionals were involved in people’s care as appropriate.

Staff were kind and knew people well. People and their relatives were involved in decisions about their care. However, advocacy information was not available to people.

People received care that respected their privacy and dignity and promoted their independence.

People received personalised care that was responsive to their needs. Care records contained information to support staff to meet people’s individual needs, though activities could be further improved so that more people could access activities outside the home.

Complaints were handled appropriately. A complaints process was in place and staff knew how to respond to complaints.

Systems were in place to monitor and improve the quality of the service provided, however, they were not fully effective. As a result the provider was not fully meeting their regulatory requirements.

People and their relatives were involved or had opportunities to be involved in the development of the service. However, actions did not always take place promptly in response to people’s comments.

We found two 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 this report.

We carried out this responsive inspection following information we had received raising concerns in respect of the care and support of people who used the service.

We considered all the evidence we had gathered under the outcomes 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?

Below is a summary of what we found. The summary is based on our observations during the inspection, discussions with people who used the service, the staff supporting them and looking at records. We also spoke with the registered manager and the provider.

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

Is the service safe?

During the inspection we spoke with some people who used the service but most people were unable to share their views and experiences with us due to their communication difficulties. We therefore spent time in communal areas and observed how people were supported. We found that people were safe.

The registered manager told us how they had faced a number of challenges to ensure that people who used the service were supported by staff who had the right values and attitudes. The registered manager told us how they had taken action when staff were not suitable and we saw them take prompt action when they observed poor practice.

We saw that care plans were in place and had been reviewed to ensure that the support people who used the service received was appropriate to meet their personal care needs.

The registered manager was aware of their responsibilities in relation to referring allegations of abuse and poor practice to the local safeguarding hub (MASH) and to CQC. Recent incidents had been reported appropriately. Staff were confident that they could recognise signs of abuse and knew how and where to report allegations of abuse. Most staff we spoke with had received training in this area, although the training matrix supplied to us by the provider only reflected that one third of staff had completed this training formally.

The registered manager told us they were aware of the principles of Deprivation of Liberty Safeguards (DoLS), and told us how they had made referrals to check that people received appropriate support. We saw that assessments to demonstrate consent and capacity were, on some occasions, still required.

We asked the provider to tell us what they would do to meet the requirements of the law in relation to safeguarding vulnerable people.

We found a number of poor care practices in relation to the storage, recording and administration of medicines. We saw that some records of administration had not been signed as given. We saw the trolley containing medicines left open while the staff member took medicine to a person who was in their room. We also saw that appropriate checks were not taken after tablets had been administered covertly.

We asked the provider to tell us what they would do to meet the requirements of the law in relation to the safe administration of medication.

Is the service effective?

We spoke with one person who used the service. They told us, “I like it here.” We saw how staff supported people. People’s personal care needs were met in a timely manner, although we found people’s social needs were not being effectively met at the time of our inspection. We saw staff interact with people as they did their jobs and spent time sitting with people. This interaction was however largely based around supporting them to eat and drink. The registered manager told us that they had appointed an activities coordinator and the provider said that there was money available to support activities. One staff member told us that a designated activities coordinator, "Will greatly improve people’s quality of life.”

We saw that care plans and risk assessments were in place to support personal care tasks and there had been an improvement in the completion of daily charts. The manager told us they were monitoring this. This meant that staff could demonstrate that they had met people’s needs.

We found systems for monitoring and assessing the quality of the service were in place however the provider did not have a system in place to record how they checked and reviewed the objectives they had set for the registered manager. Although the provider and the registered manager spoke regularly throughout the week there was nothing formally recorded about progress within the home and some objectives had not been met.

Staff told us that they felt well trained and well supported. We saw how training had been planned to ensure all mandatory courses were up to date, however the training provider had let them down. This meant that some staff had not been formally trained to meet individual support needs. The manager told us that they had to consider this when planning the rota and staff told us that they never had to do a task that they had not been trained to do.

Is the service caring?

Staff were kind and caring. Staff we spoke with told us about the people they supported and we found that staff were knowledgeable about people's individual needs and preferences. All of the staff we spoke with told us that they “Loved” their jobs.

We saw that staff took their time to support people although at times they were more focussed on the tasks rather than meeting individual needs. For example, one person was asleep and staff left their meal in front of him rather than taking it away to keep warm.

We spoke with two relatives who were visiting the home. They told us, “We can’t fault them. They are wonderful.”

We asked the provider to tell us what they would do to meet the requirements of the law in relation to care and welfare.

Is the service responsive?

We saw how the registered manager had implemented systems and structures in response to previous issues within the home. For example, they told us how they had managed staffing issues to ensure that only people suitable to work with vulnerable people were employed at the home.

We saw how care plans and accident and incident forms were reviewed and care plans were updated and amended to reflect changing needs. We saw evidence that health and social care professionals were involved in reviewing and assessing people who used the service. This meant that staff could offer effective support as people’s needs changed.

Is the service well-led?

We found that the registered manager had implemented a number of changes to ensure that the service was well led. They also told us that they had more to do to further improve the service. The provider confirmed that they had had discussions about planned changes. We recognised that staffing issues had impacted upon the registered manager’s ability to ‘manage’ the service however they told us that they were now confident that a successful recruitment drive meant that improvements would now happen.

On the day of our inspection there were 17 people who lived at Kirkby Manor. Staff told us there were sufficient staff to meet their needs. They also told us they felt well supported by the registered manager.

The provider was proactive in supporting the registered manager as they regularly visited the service and discussed issues with them. There were however no records to show how the provider monitored and assessed the quality of the service and no records that they checked what the manager was monitoring. The provider told us that they did have such a system in place in their other services.

We used a number of different methods to help us understand the experiences of people who used the service, because they had complex needs which meant they were not able to tell us their experiences. We spent time observing the delivery of care. We checked care records and quality systems. We spoke with service users, a relative, the provider, the manager and administrator, care staff, activities staff, trained nurses, clinical lead nurse and the maintenance person.

We undertook this inspection to check what improvements had been made since our last inspection in October and November 2013.

Since our last inspection there had been a reduction in the number of people using the service from 38 to 18 because admissions to the service were not taking place following the risks identified to people who used the service.

We found that the remaining 18 people who used the service were accommodated on the ground floor and the care they received ensured they were safe and their health was monitored appropriately.

We found that people who used the service received their medicines safely.

We found that there were sufficient staff employed with the right skills and experience to manage the needs of the people who used the service.

We found that the provider had employed a new manager who was in the process of registering with CQC. Staff told us they felt the home was now well led.

There were clear systems that had been put in place to monitor the quality of the service and ensure that it was effective and caring. The quality monitoring systems were supporting the provider to have a clear overview of how the service was being managed and inform them of any required action to ensure the service continued to sustain compliance with essential standards.

Care delivery supported people’s privacy and dignity. Care planning ensured that all risks were identified and plans put in place to manage the individual needs of people who used the service.

There were 29 people living at Kirkby Manor who were elderly, had enduring mental illness and dementia. We were not able to speak with people who used the service in a meaningful way due to the nature of their illness. We spoke with relatives and read reviews from external health care providers. We spoke with care staff, management staff and the provider. We looked at care records and quality monitoring systems. We observed how people were being supported.

We found that the provider had continuously improved the service since our last inspection. A new manager with the right skills had been employed and was working hard to provide quality care. There were sufficient staff who were being supported to obtain skills and qualifications in adult social care and provide them with knowledge of how to support the specific needs of the people who used the service.

We spoke with three visitors to the home and asked them if they were happy with the care being provided to their relative, comments included, “At first I thought that they would not be able to manage the needs of my relative due to the severity of the challenging behaviour. Now you would not recognise them as the same person, they are so much better and they told us that they liked the home and that staff look after them well. They have time to care here, she is well cared for and is always dressed in her own clothes.” Another commented, “I would recommend this care home to my friends and relatives.”

Prior to our visit we reviewed all the information we had received from the provider. During the visit we spoke with people who used the service and three relatives and asked them for their views. We also spoke with four care staff, two nurses on duty, the manager and the provider. A visiting GP and an NHS mental health nurse also gave us their views on the service provided and the improvements they had seen. We also looked at some of the records held in the service including the care files for four people.

We found that the required improvements had taken place and care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare and medicines were managed safely.

We used a number of different methods to help us understand the experiences of people who used the service, because they had complex needs which meant they were not able to tell us their experiences. We spoke with the manager and five staff. We also observed people had been supported by staff during mealtime and care delivery.

We found that care planning and care delivery did not always protect people from receiving unsafe care.

We found that there were sufficient staff available to support people safely but their dignity was not always maintained.

We found that the provider did not effectively monitor the quality of the service that people received and did not use the information in concerns to improve the quality of the service.

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 able to tell us their experiences.

People expressed their views and were involved in making decisions about their care and treatment. Care and treatment was planned and delivered in a way that ensured people’s safety and welfare.

We spoke with one person who used the service who told us that they were able to choose how their care was delivered, that staff respected their choices and maintained their dignity. This person told us they felt safe at the home.

Most of the people using the service were unable to provide us with information on their experience of the services provided to them.

One person told us they felt safe at the home and they told us that staff were kind and helpful, always telling them what was happening with their care.

External healthcare workers told us the staff in the home managed people's health care well.

We inspected the service on 14 and 15 October 2015. Ashfield Nursing Home is registered with the Care Quality Commission to provide accommodation for up to 40 people with mental health needs and dementia. On the day of our inspection there were 27 people living at the home.

Since the time of the last inspection the service had changed its name and was owned by a new provider. A new manager had been appointed and they had 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 our last inspection in July 2014 we found that improvements were required in relation to implementing the principles of the Mental Capacity Act 2005, managing medicines safely and assessing and monitoring the quality of the service provided. The provider, at that time, sent us an action plan detailing what action they would take to become compliant. The new providers had continued to address the issues and we identified and improvements had been made.

People who used the service told us that they felt well looked after. People’s representatives and visitors to the home told us that people were safe.

We found that staff knew how to identify potential signs of abuse. Systems were in place for staff to identify and manage risks and respond to accidents and incidents. The premises were managed to keep people safe.

There were sufficient staff on duty to meet people’s needs safely although at times, staff were rushed and this compromised the overall quality of the service provided. The process of administering medicines was safe. Staff were recruited through safe recruitment practices.

Staff received regular and ongoing supervision and support. An induction for staff was provided although staff had to wait to access some training courses. Training opportunities were improving to provide staff with the skills and understanding to carry out their roles effectively.

Overall people enjoyed a varied and balanced diet and plans were in place to improve the dining experience for everyone who used the service. People were supported to receive any health care they needed and advice provided by professionals was acted upon.

Staff were caring and treated people with dignity and respect. People and their relatives were involved in the decision making processes and care was personalised to meet individual needs. Care plans were detailed although records of decision making had not all been reviewed to reflect that they were still current.

Activities were currently limited but were improving. A complaints process was in place and staff knew how to respond to complaints.

People and their relatives were involved or had opportunities to be involved in the development of the service. Staff told us they would be confident raising any concerns with the registered manager or the providers and that they would take action. There were systems in place to monitor and improve the quality of the service provided.

People living at the home and the staff team had opportunities to be involved in discussions about the running of the home and felt the manager provided good leadership. People had been consulted and involved in plans to develop and refurbish the home.