Ashlar House is a 'care home'. People in 'care homes' receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided. Both were looked at during this inspection.

Ashlar House is registered to provide accommodation to up to 36 people who are living with dementia. It is located in the grounds of St Margaret’s hospital in Epping and provides nursing care. At the time of inspection there were 35 people living at the service. People's accommodation was situated on one floor.

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 operations manager for the provider was currently in the process registering as the manager as the previous manager had left the service.

At our last inspection in March 2017, the comprehensive the overall rating for this service was Requires Improvement. A breach of Regulation of the Health and Social Care Act 2008 (Regulated Activities) 2014 was identified. This was because people told us there was not enough staff. At our last inspection, we also identified other areas they needed to improve, staff refresher training was overdue, staff had not received a recent appraisal and people were not always supported to take part in activities. The registered provider sent us an action plan detailing the improvements they would make. They kept us informed of their progress.

Staffing levels had improved since our last inspection and people’s needs were now met in a timely manner. The provider completed relevant pre-employment checks to ensure staff were safe to work with older people. Medicines were managed safely and administered as prescribed.

The staff received training and support to ensure they had the skills to provide people's support in a safe way. The provider kept an overview to ensure refresher training, supervision and appraisals were kept up to date.

People were provided with activities and entertainment of their choosing and regularly accessed activities within the community. People knew how to raise concerns and were confident any concerns would be listened and responded to.

There were systems in place to minimise risks to people and to keep them safe. When we identified a concern related to one person’s behaviour support plan and risk assessment the provider responded immediately. People were relaxed and at ease in their surroundings and told us they felt safe. Procedures were in place, which safeguarded the people who used the service from the potential risk of abuse.

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 worked closely with healthcare professionals to promote people's well-being, and make sure health needs were monitored. People’s nutritional needs were assessed and professional advice and support was obtained for people when needed.

People had the opportunity to give their views about the service and feedback was acted upon in order to ensure improvements were made to the service when required. The service had a robust quality assurance system and identified shortfalls were addressed.

At our last inspection on 16 and 21 July 2015 the service was rated good overall. The current registered manager had been in post since September 2016 and had just recently registered with us. 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.

Some of the people using the service and their relatives felt there were not enough members of staff to support them properly. The provider addressed this immediately and increased the staffing during the morning.

People were not always supported to follow their interests and limited activity or stimulation was provided. The registered manager had recognised this and an activity co-ordinator was about to commence work at the service.

We looked at people's care records and saw that people had detailed risk assessments and plans in place to manage risks in order to keep people safe. People told us they felt safe

The registered manager had systems and processes in place to ensure that staff were kept up to date with their core training. We saw that there were some gaps in staff training, however the registered manager had plans in place to ensure this was delivered.

We saw that people's needs had been assessed and care plans had been put in place for staff to follow to ensure people's needs were met. People had been referred for specialist input and advice received had been followed. Staff were made aware of people's changing needs.

People who used the service felt they could talk to the registered manager and that they would address any issues if required. Relatives found the registered manager to be approachable.

Systems were in place to monitor the quality of the service being provided but the registered manager had not had sufficient time since appointment to address the issues identified. The registered manager had begun the process of addressing shortfalls in supervision and appraisals.

We considered all the evidence we had gathered under the outcomes we had inspected to answer the questions we always ask; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Is the service safe?

People’s care records contained risk assessments and care plans to ensure the care provided was safe and appropriate for their needs. Care plans were reviewed in conjunction with the people who used the service, and their relatives where appropriate, to ensure care was provided in accordance with their wishes.

The servicee had policies in place in relation to Adult Safeguarding, the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards. Mental capacity assessments were completed when people lacked capacity to make decisions in relation to their care and treatment and best interest decisions documented. Staff had received training and demonstrated an understanding of the implications of the policies in relation to their practice. This meant people’s rights could be protected.

Policies and procedures to prevent and control the spread of infection were seen. Cleaning schedules were in place and the standards of cleanliness monitored through regular spot checks and audits to ensure that cleanliness was maintained. We saw staff washing their hands prior to providing care and serving meals and wearing protective clothing as necessary. This meant steps were taken to protect people from infection and keep them safe.

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Is the service effective?

Full assessments of each person were undertaken prior to their admission to the service. Care plans were reviewed regularly and updated as necessary to ensure the care provided was appropriate to each person’s individual needs.

We saw there was involvement of a range of professionals in the care of each person to ensure care was effective and specialist input obtained where necessary.

There was a structured approach to training and appraisal of staff to ensure staff were supported to function effectively in their job roles.

Is the service caring?

When we talked to people who used the service and their relatives, they told us that staff were caring and understood people’s individual needs and preferences. We observed a good rapport between the people who used the service and the staff which demonstrated their empathy and sensitivity to people’s needs and wishes.

Several people had visitors during the inspection and the visitors told us they were able to visit at any time and staff always greeted them warmly and were welcoming.

People were encouraged to participate in activities they enjoyed both individually and as part of a group thus promoting their well-being.

Is the service responsive?

Systems were in place to make sure that themes and trends from events such as accidents and incidents, complaints, and concerns were identified and lessons learnt to prevent recurrence. This reduced the risks to people and helped the service to continually improve.

Feedback on the service was sought from people and their relatives and we saw a number of examples of improvements which had been implemented as a result of this feedback .

People told us they had had no need to complain but if they raised a concern or issue of any kind they were confident it would be addressed. They said staff were approachable and always listened to their views.

Is the service well led?

There were structures in place for clinical governance and quality assurance. We saw a planned approach to quality audits and evidence that action was taken as a result of these to improve the quality of the service provided.

Staff told us they felt well supported and encouraged to provide standards of care they could be proud of. They had received the training they required to deliver safe and effective care. There were systems in place for the appraisal of staff and personal development planning.

Key areas we looked at such as infection control and consent to care and treatment were supported by policies and procedures which identified the standards and practices expected.

During the course of our inspection we saw there were many visitors who spent time with people in the home. We spoke with nine people who used the service and 12 visitors. The comments they gave were all positive. For example, one visitor told us, “I am very happy with the service; I think they all do their best at all times. The carers work extremely hard, I have never seen anything I do not approve of.” Another person said, “It’s very cheery, it’s nice. Whatever you ask of them they do they are simply wonderful.”

People told us that the care and support people received from the staff and management team was good. One person told us, “I think the staff are marvellous, caring, loving, patient and long suffering. Whether I am here or not the care is always here. I am confident to leave [relative] in their charge.”

We found that the provider had comprehensive and up to date safeguarding and whistle-blowing policies in place. Information about complaints and safeguarding was displayed in communal areas in the home for staff, visitors and residents to refer to.

We saw that the provider had carried out checks on staff to ensure they were suitable to work in this environment. Visitors to the home made positive comments about the staff team. One person told us, “I have always found the staff to be very helpful and caring. I think everybody does their best in bordering on an impossible situation.”

We spoke with four relatives who visited and assisted their relative over lunch. They spoke highly of the home and the way that care was provided. They all felt comfortable raising issues with the manager and staff. They also felt included in care decisions of their relative.

Comments made included, “Excellent care.” One relative said, “There are no angels, but the staff here come pretty close.” Another relative said, “It’s a very good home. Any complaints are dealt with. We never had anything other than very minor complaints over the years.”

A person spoken with said, “It’s lovely here. Staff are very nice and friendly.” Another person said, “Everyone is really nice here.”

We found that people and their relatives were involved in care plans and preferences were generally known and met by competent staff.

Care plans were comprehensive and risks identified were acted on. Other external professionals were actively involved in supporting the person's needs with some success noted in relation to wound care and nutrition.

People's nutritional needs were being met. Where people were known to be at risk of excessive weight loss or dehydration, extra support was provided by staff and external professionals and closely monitored by the Registered Manager.

Medication was safely managed and administered at the home.

We found suitable and sufficient levels of competent staff to meet the needs of people at the home.

Many people using the service were unable to tell us their views on the care they received due to cognitive impairment or dementia. We saw that people were well supported and that care was delivered with sensitivity and respect.

All the visitors we spoke with told us that peoples’ dignity was respected at Ashlar House and that they felt their relative was safe there. People also spoke very highly of the staff at Ashlar House and complimented their levels of caring and ability to support the people living there. They told us that staff took time to talk and interact with people in a positive way.

People described the care as “excellent” and “very good”. They had been involved in the assessment and plan of care of people living at the home and had been able to advise staff of people's preferences and interests. People told us that there was a good range of meaningful and stimulating activities and occupations for people living at the home that met their individual needs.

People told us that the premises was suitable to the needs of the people living there and that was it always clean and there were never any nasty smells.

Visitors told us that there were opportunities for them and for people living at Ashlar House to give their views on the service. They told us they had no complaints at all about the service and that they would feel able to raise any issues as everybody was approachable.

This inspection took place on 3 and 4 June 2015 and was unannounced.

Ashlar House is registered to provide accommodation for 36 older people who require nursing and personal care. People may also have needs associated with dementia. There were 28 people living at the service on the day of our inspection, including two people who were in hospital.

A registered manager was not in post in the service. 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 had notified us as required that the registered manager had resigned. An interim manager was newly appointed to lead the service until the new manager could take up their post.

Staff had attended training on safeguarding people. They were knowledgeable about identifying abuse and how to report it. Recruitment procedures were thorough. Risk management plans were in place to support people to have as much independence as possible while keeping them safe. There were also processes in place to manage any risks in relation to the running of the home.

Medicines were safely stored and administered in line with current guidance to ensure people received their prescribed medicines to meet their needs.

People were supported by skilled staff who knew them well and were available in sufficient numbers to meet people's needs effectively.

Staff were well trained and used their training effectively to support people. Staff understood and complied with the requirements of the Mental Capacity Act 2005 and the associated Deprivation of Liberty Safeguards.

People had regular access to healthcare professionals. A wide choice of food and drinks was available to people that reflected their nutritional needs, and took into account their personal lifestyle preferences or health care needs.

Staff were kind and caring in their approach to people. People’s dignity and privacy was respected. Visitors were welcomed and people were supported to maintain relationships and participate in meaningful activities.

Care plans were regularly reviewed and showed that the person, or where appropriate their relatives, had been involved. They included people’s preferences and individual needs so that staff had clear information on how to give people the care that they needed. People told us that they received the care they needed.

People living and working in the service had opportunity to say how they felt about the home and the service it provided. Their views were listened to and actions were taken in response. The provider had robust systems in place to check on the quality and safety of the service provided, to put actions plans in place where needed, and to check that these were completed.