Ashgrove Care Home – London is a nursing home for older people who are living with the experience of dementia. The home is registered for up to 50 older people. At the time of our inspection 47 people were living at the service. Care is provided over two floors. The provider employs nursing and care staff to support and care for people. The service is managed by HC-One Limited, a national provider of nursing and care homes.

At the last inspection of the service on 7 October 2014 we rated the service Good. The key question of Caring was rated Requires Improvement. We did not find any breaches of Regulation.

This was a comprehensive inspection of the service which took place on 4 July 2017 and the service remained Good.

People were happy and comfortable living at the service. They appeared relaxed and were unrestricted in their access to parts of the home and garden. The staff were attentive and caring and people had plenty to do. They were offered a range of food and drink and were able to make choices about how they spent their time, what they ate and where they went. There was a range of organised activities which people were able to participate in. There was also a number of games, puzzles, toys, colouring books and pens and other resources which people were able to help themselves to and the staff offered them.

Visitors were happy with the service, they felt people were safely cared for. They were free to visit the home whenever they wanted and they felt well informed.

The staff were recruited in a suitable way and they had training and information to help them to understand their roles. They felt well supported and told us they could speak with the registered manager about any concerns they had or any questions about their work.

The staff worked well as a team helping each other to make sure people's needs were being met.

People's needs were assessed and planned for. There was clear information about how to meet these needs. This information was regularly reviewed and updated when needed. The staff worked with other healthcare professionals to monitor and meet health needs.

The environment was kept safe and clean, with the exception of a small number of areas which needed deep cleaning. The environment did not meet best practice guidelines in respect of orientation and meeting the visual and sensory needs of people living with the experience of dementia. We made a recommendation in relation to this.

The registered manager knew the needs of the service well. They were familiar with all the staff and people who lived there. People felt comfortable talking with the registered manager. There were good systems for monitoring the quality of the service and making sure improvements were made where needed. These systems included audits and checks by the staff and the provider.

We saw that the provider listened to the views of people who used the service, their visitors and the staff and they made changes when people asked for these.

We spoke with two people using the service, two relatives, two members of staff and the registered manager. We also received information from the local authority and Hounslow Clinical Commissioning Group. At the time of the inspection there were 37 people using the service.

The inspection was carried out by an inspector during one day. This helped answer four of our five questions;

• Is the service safe?

• Is the service caring?

• Is the service responsive?

• Is the service well led?

During this inspection we did not review any information in relation to the question ‘Is the service effective?

Below is a summary of what we found. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

During our inspection we noted that there was a strong malodour which was noticeable around the ground floor lounge and reception area. The armchairs in the ground floor lounge were stained and had an odour. We saw the toilet seat in a ground floor bathroom was broken and this was repaired before the end of our inspection.

We saw that the fluid balance and food charts for people using the service had been regularly completed and were up to date for the day of the inspection. We did note that some of the records did not have the total fluid balance for each day calculated or details of what food was eaten.

We saw two electronic keypad access systems, one on the door to the ground floor lounge and one between the corridor with bedrooms and the reception area. This restricted people’s access to the lounge or their bedrooms. These keypads were removed the day after our inspection after we discussed risk assessments in relation to their use with the management of the service.

Is the service effective?

We did not review information in relation to this question.

Is the service caring?

We saw that most people were supported by kind, attentive staff who treated them with respect and dignity. We carried out a SOFI (short observational tool for inspectors) over the lunch period at the home where we observed that one member of staff was responsible for providing support for five people in the ground floor dining room which resulted in their independence not being promoted and dignity not being maintained. Some of the people in the ground floor lounge were unable to choose where they ate their lunch.

Is the service responsive?

During our last inspection in February 2014 we found that people were not kept occupied and stimulated as fully as they could have been. The people we spoke with told us they were sometimes bored in the home and there was not much to do. During this visit we saw the activity coordinator supporting people who had chosen to take part in different activities. The activities coordinator told us they were in the process of developing a range of new activities. One relative said "I think the activities have improved over the last few months but things could still be better. The colouring activity is not really appropriate for everyone".

During our previous inspection in February 2014 nursing staff were unable to tell us about people on their floor receiving treatment for pressure sores. During this visit nursing staff were able to tell us how many people on their floor had a pressure ulcer, the grade and the treatment being provided. We also saw up to date records detailing their care.

Is the service well led?

The service had provided a nurse’s office on each floor where the records including care plans and risk assessment were kept securely. The fluid balance and food charts were located in a cupboard in each lounge so staff could assess them easily.

We spoke with four people who use the service, two relatives and six members of staff to gain their views of the service. People and their relatives were overall satisfied with the care and support provided by the home.

The care records appropriately addressed people’s needs and had been reviewed at least monthly to ensure they reflected people’s needs. The care records were drawn up with people or their relatives. However, we found that people were not always involved in their reviews every three to six months according to the home’s policy on the review of people’s care records.

Other records had been completed to describe the care people received or to monitor their oral intake. Some records were stored safely but a few were not stored that safely which meant people’s records could be accessed by other people not entitled to see them. We found that some of the records about people’s oral intake were not completed in a timely manner and were completed retrospectively bringing in a possibility of inaccuracies.

Where required various healthcare professionals were involved in people’s care and treatment and appropriate records were kept to describe their input into people’s care and treatment. We found that communication and handover in the home did not work so well, because on the day of the inspection nursing staff did not know that a person had a grade 3 pressure ulcer. This meant that they could not monitor or give nursing care and treatment to the person in relation to the pressure ulcer.

Medicines management was generally carried out to a good standard to ensure people were protected from the associated risks.

People said they were treated well and staff were nice to them. Relatives confirmed this. Staff received ongoing training, regular supervision and appraisal and had the opportunity to attend monthly staff meetings.

The service had some arrangements in place to gain people’s and relatives’ views of the quality of the service provided. There were also other processes in place to monitor and assess the quality of the service so people received appropriate care and treatment.

We spoke with thirteen staff, four people using the service, one healthcare professional and one relative.

People said they were involved in discussions about their care and treatment and were happy with the care they received. We observed staff supporting and assisting people during the inspection and they were communicating effectively with people. One person said, “I am very pleased to be here”.

Input from health and social care professionals was easily accessible and was documented. One healthcare professional confirmed the staff followed their instructions so people received the treatment they needed for their conditions to improve.

Overall medicines were well managed at the home and the registered nurses explained people’s medication to them when they administered it.

At the time of inspection there were enough staff on duty to meet people’s needs. The majority of staff spoken with felt the home was being staffed to meet people’s needs. One person said, “the staff are very good to me” and another said, “staff are brilliant”.

There was a complaints procedure in place and staff said if anyone wanted to raise a concern they would listen to them and ask them to speak with the registered nurses or the manager so that the complaint could be addressed. People said they would feel confident to discuss any issues, and one person said a concern had been addressed promptly when raised.

People said staff treated them with respect and they liked living at the home. Comments people made about the staff included they were “lovely” and “could not be better”. One person who needed help at mealtimes said staff assisted them at an appropriate pace with their meals. Another person told us staff answered their call bell promptly. People said they were offered choices, for example with meal options. We saw the menu choice lists that had been completed for the day of our visit and which identified the meal chosen by each person.

People said staff were available to assist and support them. One person said “there is always someone to help me” and another person said “the staff are very kind”. Other people also expressed their satisfaction with the support and care the staff gave to them. People confirmed they were able to see the GP when they needed to and they saw other healthcare professionals, for example the dentist. People and representatives also confirmed staff followed any instructions received from the healthcare professionals. Some people had individual activities they enjoyed and we saw they had been provided with the items they needed to pursue these. People we asked confirmed they felt safe at the home and could speak with the manager and the staff if they had any concerns.

This inspection took place on the 6 and 7 October 2014 and was unannounced.

Ashgrove Nursing Home provides accommodation and nursing care for a maximum of 50 older people with dementia and/or mental health needs. At the time of our visit there were 40 people using the service.

The service 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 and associated Regulations about how the service is run.

The provider did not meet all of the regulations we inspected against at our last inspection on 8 July 2014. The provider was not meeting the legal requirement in relation to infection control and promoting people’s independence and dignity. We saw that people using the service, staff and visitors were not protected from the risks of infection as an appropriate standard of cleanliness and hygiene was not maintained in some areas of the home. We also saw that there were not enough staff to provide appropriate support for people during meals. During this inspection we saw that the provider was now meeting the regulations as improvements had been made in the cleaning and infection control procedures at the home with new armchairs being used in the lounges. We also saw there was enough staff to provide people with the appropriate level of support they required during meals but, at times, some staff were not engaging with people using the service to explain what was happening and they could still be task focused instead of considering people’s needs.

During this inspection people using the service and relatives told us they felt the care they received was safe. There were policies and procedures in place to respond to any concerns about the care received. Staff had completed safeguarding training and could explain how they would respond to any concerns.

The service had a system in place to record and identify any learning from incidents and accidents.

There was a clear process and procedure in place for the safe administration of medicines that had been prescribed to people using the service. We saw the Medicines Administration Record (MAR) charts were up to date and the information was clearly recorded.

We saw people had a choice of meals and drinks with that day’s menu displayed in the dining rooms and lounges. People told us they were happy with the food provided by the home.

We saw the service had carried out initial capacity assessments in relation to a person’s ability to make specific decisions about their life. The manager was aware that appropriate authorisation was required where a person might be deprived of their liberty and was in the process of making a Deprivation of Liberty Safeguards (DoLS) application to the local authority for people using the service.

The provider had a clear induction for new staff and supervision process in place. Staff completed a range of training identified as mandatory by the provider to help meet the support needs of the people using the service.

During our visit we saw one occasion when a staff member did not maintain a person’s dignity and privacy during personal care. Throughout the rest of our visit we saw staff treated people with dignity, respect and supported people to make choices about the care they received.

People’s care needs were assessed when they initially moved into the home and we saw their care plans and risk assessments were regularly reviewed. Information about the person’s life experiences, likes and dislikes was used in the development of their care plans.

People using the service, their relatives and health and social care professionals involved in people’s care were sent questionnaires to get their opinion on the support staff provided and regular relatives meetings were held. This enabled the provider to identify good care and any areas requiring improvement. The service has a robust audit process in place to monitor the quality of the care provided.