Ashfields 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 provides residential care in a purpose built building for up to 44 older people, the majority of whom are living with dementia. There were 39 people living in the service when we inspected on 19 March 2018. This was an unannounced comprehensive inspection.

We last inspected this service in November 2016 and rated the service as required improvement. During that inspection, we found that, although effective systems were in place to monitor the quality and safety of the care provided in most areas, the provider had not effectively assessed and monitored that people received enough to drink to meet their individual needs. There were not always sufficient staff on duty to support people; this had an impact at mealtimes, which meant that sometimes people had to wait for assistance. Risks in relation to people developing a pressure ulcer required improvement. This was because people assessed as being at a high of developing a pressure ulcer were observed as not using specialist equipment to protect them, people were seen not using their pressure relieving cushion. This meant that the systems in place to assess and monitor the quality of care provided were not effective.

Following the last inspection, we asked the provider to complete an action plan telling us what improvements they would make to bring the service to at least Good. During this inspection on 19 March 2018, we found that improvements had been made to meet the requirements to help ensure that people received a good service.

Ashfields has a newly 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 new registered manager took up their post in December 2017 shortly after the previous manager left in that month.

People who spoke with us and relatives said they believed their relatives were safe and well cared for.

There were systems in place that provided guidance for staff on how to safeguard the people who used the service from the potential risk of abuse. Staff understood their roles and responsibilities in keeping people safe. There were processes in place to ensure the safety of the people who used the service. These included risk assessments, which identified how risks to people were minimised.

There were sufficient numbers of trained and well supported staff to keep people safe and to meet their needs. Where people required assistance to take their medicines there were arrangements in place to provide this support safely, following best practice guidelines.

Both the registered manager and the staff understood their obligations under the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). The registered manager knew how to make a referral if required. 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 support this practice.

People were supported to eat and drink enough to maintain a balanced diet. They were also supported to maintain good health and access healthcare services.

There were arrangements in place to make sure the service was kept clean and hygienic.

We saw many examples of positive and caring interactions between the staff and people living in the service. People were able to express their views and staff listened to what they said and took action to ensure their decisions were acted on. Staff protected people’s privacy and d

This inspection took place on 2 and 4 November 2016. The first day was unannounced.

Ashfields is a service that provides accommodation and personal care for up to 44 people. During the inspection visit, there were 38 people living within the home, most of whom were living with dementia.

There was a registered manager employed at 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 and associated Regulations about how the home is run.

At the last inspection on 13 January 2015, we asked the provider to take action to make improvements to the management of people’s medicines, assisting people to eat and drink enough to meet their needs and to their processes to monitor the quality of care provided. At this inspection, we found that some improvements had been made. However, although effective systems were in place to monitor the quality and safety of the care provided in most areas, the provider had not effectively assessed and monitored that people received enough to drink to meet their individual needs. You can see what action we have told the provider to take at the back of the full version of this report.

The provider has assessed the number of staff required to provide people with safe care that met their needs. However, the required number had not always been reached resulting in less staff working on some days than there should have been. This placed people at risk of not receiving care in a timely manner or care that met their needs. The provider had recognised this and was making improvements within this area.

Risks to people’s safety had been assessed and in most cases, actions had been taken to reduce any risks that had been identified. However, risks in relation to people developing a pressure ulcer required improvement.

Systems were in place to reduce the risk of people experiencing abuse. Risks in relation to the premises had been assessed and the home was well maintained. Equipment that people used had been tested to make sure it was safe to use and people received their medicines when they needed them.

The staff were kind, caring and compassionate. They treated people with respect and upheld their dignity. They provided people with choice so they could make decisions about how they wanted to be cared for. People’s individual care needs had been assessed and they were encouraged to join in with a variety of different activities to enhance their wellbeing.

People had access to a good choice of freshly prepared meals and snacks. Staff sought advice from other healthcare professionals and acted in a timely manner when any concerns about people’s health had been identified.

The staff requested people’s consent before they provided them with care. Where people were not able to give consent, the staff made sure that they took any decisions they made on their behalf in the person’s best interests.

Staff had the necessary skills and knowledge to enable them to provide people with effective care. The registered manager monitored the completion of their training to make sure it was up to date and appropriate.

The provider had identified that they wanted to improve the quality of care being provided to people living in the home, the ultimate aim of which was to improve people’s quality of life and wellbeing. Improvements had commenced which involved staff receiving further training regarding supporting people living dementia and making changes to the environment.

This inspection was unannounced and took place on 13 January 2015.

At our last inspection on 08 and 11 July 2014, we asked the provider to make improvements in respect of concerns about the lack of adherence to the Mental Capacity Act (MCA), ensuring that people’s needs were met and with the staffing levels provided. An action plan that told us how and by when the necessary improvements would be made was completed by the provider and the anticipated outcomes considered as part of this inspection.

During this inspection we checked on their improvement plan and found that action had been taken about adherence to the MCA and ensuring people’s needs were met. However improvement had not been made to staffing levels.

Ashfields provides care and accommodation for up to 44 older people who are living with dementia. On the day of this inspection there were 40 people living at this home.

This service is required to have a registered manager in day to day charge of 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.

There were discrepencies in the administration of controlled drugs. The quantities of some drugs did not correspond to the amounts recorded in the controlled drugs register. There were gaps in the medication administration records of other medicines administered by staff. You can see what action we have told the provider to take at the back of the full version of this report.

People did not always receive the support and assistance they needed to eat and drink. Some people did not receive assistance in a timely way so that their food or drink had gone cold by the time staff were available to help them. You can see what action we have told the provider to take at the back of the full version of this report.

On the day of our inspection the home was being managed by the deputy manager, who was also providing care support due to staff shortages. During our inspection staff were not organised and did not receive clear direction about the tasks needed to be completed and who was responsible for them. There was a lack of oversight and support from the provider. You can see what action we have told the provider to take at the back of the full version of this report.

Staff knew about the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). They understood how this legislation affected the way they supported people and acted in the person’s best interests.

Care plans provided sufficient information to staff on how to support people. Other records about people’s care were not consistently completed. Where necessary, staff involved other professionals in people’s care. Staff were alert to changes in people’s physical and mental health and referred to other professionals promptly.

People were offered choices and supported to make decisions around daily living. Although staff were hurried, they were always kind, compassionate and caring towards people. Staff worked hard to find time to speak with people and raise a laugh.

People were unable to speak with us because they were living with dementia and so we observed how staff interacted with them during the evening meal. We saw that staff were friendly, warm and kind to people, giving them as much time as they needed in order to make themselves understood. People appeared happy and content and they were encouraged to be as independent as possible. For example, one person was given a plate guard so that they could eat without help from staff.

We saw that people were treated with respect and their dignity and independence was protected by staff who knew them and understood their needs well. People's care records reflected their individual needs and how they should be met. Regular reviews of care took place and any changes made known to staff.

The home was clean, tidy and free of unpleasant smells. Cleaning schedules were in place and up to date. Staff understood the need for infection control and there were effective systems in place to reduce the risk and spread of infection.

Staff told us they felt well supported and we saw that regular supervision and annual appraisals took place in order to identify training and other needs. Staff were trained to meet the specific needs of the people living at this home.

Records were well maintained, legible and easily accessible to staff. Personal records were stored securely and accessible only to relevant staff. They contained the information staff needed to care for people effectively.

We haven’t been able to speak with many people using the service because people at this service had complex needs which meant they were not able to tell us their experiences. We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

Those people who were able to speak with us said, “This is a very nice place to be.” We were also told, “We are well looked after and the staff are very very nice.”

Most people living in the home were not able to tell us verbally what they thought about the quality of the service and the support they received. Because of this, we spent time observing what was going on in the home and speaking to people visiting and working there.

Two people were able to tell us that the food was lovely and that they had enjoyed their meal.

One adult social care inspected this service, and at the time of the inspection there were 43 people using the service.

We spoke with people who used the service, a relative and a number of staff. We reviewed six people’s care records and charts and 10 staff records. We also reviewed a selection of other records in relation to accidents and injuries and audit results.

We used the evidence we collected during our inspection to answer five questions.

Is the service safe?

People told us that they felt safe and the staff we spoke with understood their responsibility in relation to safeguarding vulnerable adults. The provider had policies and procedures in place to help protect people from the risk of abuse.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. At the time of the inspection the trainee manager was in the process of submitting an application for a person assessed as requiring this safeguard. We noted that they were following the correct procedure in applying for this authorisation.

However, where people did not have the capacity to consent, the provider had not always acted in accordance with legal requirements. We found that not everyone, who may have needed to be, had been assessed in relation to their capacity to make day-to-day decisions. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to consent to care and support.

Generally, there were enough suitably qualified and experienced staff to meet the needs of the people who used the service. However, during our inspection we noted that the lounge, where people with more advanced dementia spent their time, was not staffed at all times during the day. We saw evidence that this put people at risk. The risks were in relation to people’s immobility, unsafe mobility, not being able to change their own position and not meeting people’s emotional needs. During one occasion when the lounge was not staffed, a person slid from their chair on to the floor. We also observed one person repeatedly calling out and asking why no ‘nurses’ were present in the room to help her. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to adequate staffing to ensure the needs of people are met.

There were effective procedures in place to manage and mitigate foreseeable emergencies. The staff we spoke with were aware of these procedures and told us that they knew what they should do in the event of an emergency.

Is the service effective?

We noted that nationally recognised screening tools were used including the assessment of people at risk from malnutrition and pressure ulcers. We noted that the results from these assessments adequately informed people’s care plans. This included people being assisted to eat and drink, and people at risk of developing pressure ulcers, being positioned on air-flow beds and pressure relieving cushions. We saw evidence that sensors were used in people’s individual rooms that alerted staff when people got out of bed. This meant that staff could attend to them in a timely manner. The trainee manager told us that the number of falls in people’s rooms had reduced since the introduction of the sensors.

However, we noted that there were numerous gaps in people’s records in relation to their repositioning, oral care, recording of fluid and diet intake and their weights. This meant that people could be at risk of deterioration because regular reviews of people’s health and wellbeing were not being recorded. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to ensuring the welfare and safety of people using the service.

Is the service caring?

We could not speak with some of the people using the service because they had complex needs or communication difficulties which meant that they were not able to tell us their experiences. However, we noted that staff interacted positively with these people and used different means of non-verbal communication to try and ensure people’s needs were being met. The people we did speak with told us that they were happy living in Ashfields. One person said, “I have been here a long time and am very happy. The food is lovely and I get well looked after.” Another person said, “It’s wonderful here. The staff help me with everything and I have no complaints.”

During our inspection we observed staff, at all times, caring for and supporting people in a compassionate and respectful manner. Staff were patient at all times and took their time when assisting people. It was evident that the staff knew the needs of people well and gave person-centred care.

Is the service responsive?

We saw evidence that the service was generally responsive to people’s social and emotional needs. There was some outstanding practice in relation to the activities available to people, including group and individual activities. The activities coordinators clearly matched activities and social interaction to meet the individual needs of people, and promoted people’s inclusion in the community. This included assisting people to church and facilitating trips out. People’s activity during the day was documented in detail including any changes in their mood and their communication and mobility needs.

Residents and relatives meetings took place every third month and there was an annual satisfaction survey for people to complete to determine their thoughts and comments about the service. We noted that people were positive about the service and relatives felt that their relations were well cared for.

The trainee manager told us that the management team had an ‘open door’ policy for people using the service and their relatives to enable them to raise any concerns or complaints. We noted that complaints were minimal. Complaints were appropriately documented and we saw evidence that they had been investigated and resolved.

Is the service well-led?

At the time of our inspection we spoke with the trainee manager as the registered manager was on leave. They told us that they were in a training position because the provider advocated succession planning to reduce the risk of a service being left without a registered manager if they chose to leave.

We observed a positive culture within the service. All of the staff we spoke with told us that they felt well supported and spoke positively about the management team. We noted that there were regular staff meetings and that staff were encouraged to raise comments in order to help improve the quality of the service. All of the staff we spoke with said that they felt the management team were responsive to their ideas and supported new initiatives. These included the current maintenance works that were being undertaken to improve the layout of the building including a ‘café’ area for people using the service, and the proposed ideas for creating ‘shop fronts’ to help stimulate the minds of people living in Ashfields regarding shops and activities in the community.

The service had quality assurance systems in place to assess and monitor the quality of the service people received. We noted that there were action plans to address any identified shortfalls in service provision.