We carried out an unannounced inspection of the service on 11 May 2015. Ashley Care Centre provides accommodation for persons who require nursing or personal care and the treatment of disease, disorder or injury for up to 49 people. On the day of our inspection 47 people were using the service and there was a registered manager in place.

At the last inspection, in June 2015, the service was rated Good. At this inspection we found that the service remained Good. However, the rating for the Effective domain has changed from Good to Requires Improvement.

People continued to receive safe care. Safe staff recruitment processes were in place and people were protected from the risk of harm. Enough staff were in place to provide care and support to people to meet their needs. Safe medicine management processes were in place and people received their prescribed medicines safely.

Since our last inspection we found improvements were needed to the way the principles of the Mental Capacity Act 2005 (MCA) were used when decisions were made for people. People were supported to lead a healthy lifestyle. Records used to record current risks for some people in relation to their nutritional needs required updating. Staff were well trained and understood how to provide effective care and support for people. Staff received regular supervision of their work and were encouraged to develop their roles through gaining relevant external qualifications. Effective relationships were in place with external health and social care professionals to support people with their day to day health needs.

People were treated with kindness, dignity and respect by the staff. People had developed positive relationships with staff which contributed to a positive atmosphere within the home. People’s care records were detailed and personalised which enabled staff to support people in line with their personal preferences. People felt able to make a complaint if they needed and were confident any concerns raised would be acted on. Effective systems were in place to manage any complaints that the provider may receive.

The service continued to be well-led. The registered manager, new to the role since the last inspection and their clinical lead, managed the home enthusiastically and professionally. People, relatives, staff and professionals commented positively about their leadership. There was a positive ethos and an open culture at the home resulting in an enjoyable working environment for staff and a calm and friendly atmosphere for people living there. Effective auditing processes were in place.

We carried out an unannounced inspection of the service on 25 June 2015. Ashley Care Centre provides accommodation for persons who require nursing or personal care, diagnostic and screening procedures and the treatment of disease, disorder or injury for up to 49 people. On the day of our inspection 47 people were using the service and there was a registered manager 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.

At our previous inspection on 18 and 21 July 2014 we asked the provider to take action to make improvements to the areas of care and welfare of people who use services and cleanliness and infection control. We received an action plan in which the provider told us the actions they had taken to meet the relevant legal requirements. At this inspection we found that improvements had been made.

The risk to people experiencing abuse at the home was reduced because staff had received training on safeguarding of adults, could identify the different types of abuse and knew who to report concerns to. Accidents and incidents were investigated and then plans were put in place to reduce the risk people’s safety. Personal emergency evacuation plans were now in place for all people and these were regularly reviewed. There were enough staff with the right skills and experience to meet people’s needs. Medicines were stored, administered and handled safely. Protocols for the administration of ‘as needed’ medicines were in place for the majority of people who needed them, although there were a small number of examples where they were not. There were clear processes in place to reduce the risk of the spread of infection.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) and to report on what we find. The DoLS are part of the MCA. They aim to make sure that people are looked after in a way that does not restrict their freedom. The safeguards should ensure that a person is only deprived of their liberty in a safe and correct way, and that this is only done when it is in the best interests of the person and there is no other way to look after them. The registered manager had applied the principles of the MCA and DoLS appropriately.

People were supported by staff who had received the appropriate training to support people effectively. People spoke positively about the food they received and staff supported and provided specially adapted equipment for people who wished to eat and drink independently. People’s food and fluid intake was monitored and where a risk of a person becoming dehydrated or losing or gaining weight was identified, guidance to manage this effectively was requested from dieticians. People had regular access to their GP and other health care professionals.

People were supported by staff who were caring and treated them with kindness, respect and dignity. Staff spoke respectfully about people. Where people showed signs of distress or discomfort, staff responded to them quickly. Staff listened to people and made them feel that they mattered. People were supported to access an independent advocate if they wanted to, although the information provided needed to be more accessible for people. There were no restrictions on friends and relatives visiting their family members. People could have privacy when needed and there was sufficient space for people be alone if they wanted to be.

People and their relatives were involved with the planning of the care and support provided. Care plans were written in a way that focused on people’s choices and preferences. Adjustments had been made to the service to support people living with dementia. Regular monitoring of people’s assessed needs was conducted to ensure staff responded appropriately. People were able to access the activities and hobbies that interested them. A new mini bus had been purchased to improve people’s ability to undertake activities outside of the home. A complaints procedure was in place, although information about who to report concerns to externally was not always provided.

There was a positive atmosphere within the home and people were encouraged to contribute to decisions to improve and develop the service. Staff understood the values and aims of the service and were aware of how they could contribute to reduce the risk to people’s health and safety. There was a strong registered manager in place who led the service well. People spoke highly of them. The registered manager had clear processes in place to manage the risks to people and the service. They continually used guidance from external professionals and other managers of local adult social care services to improve the quality of the service people received. Robust auditing and quality monitoring processes were in place.

During the inspection we spoke with four people who used the service, six relatives, the kitchen assistant, a care assistant, a senior care assistant, a registered nurse, the manager, the general manager and the owner. We conducted a tour of the building and reviewed records relevant to the management of the service.

People we spoke with told us that staff gained their consent before providing care and treatment. A relative of a person who used the service told us, “I am involved; I have seen my family member’s care plan. I always have a good chat with the staff. I am kept up to date with what is happening.”

We saw that the food and drink provided met people's needs. A relative told us, “My family member is a vegetarian; there is always a good vegetarian option available.”

There were enough qualified, skilled and experienced staff to meet people's needs. A person who used the service told us, “I am never left alone for long, they (staff) always come when I need them.”

We saw there was an effective complaints system available. A person who used the service told us, “I have never had to complain but do know how to if I need to.”

We used a number of different ways to help us understand the experiences of people who used the service. This was because people had complex needs which meant that they were not able to tell us about their experiences.

We looked at records, including personal care plans. We spoke with four people who were visiting the home. We also spoke to the manager and staff who were supporting people, and we observed how they provided that support.

We also knew that the Nottinghamshire County Local Involvement Network (LINk) undertook a visit to the home on 30 April 2012. The overall outcome of the visit was positive and comments made in their report ranged from, “It is good practice that the staff all appear to take time to sit, talk and listen to residents as part of their duties.” to, “There are named Dignity Champions although all staff have had Dignity in Care training. The Dignity of the Residents seems to be a matter of huge importance at this home.”

During our visit we saw that staff supported people in a respectful and dignified way, and that they closely followed the care that was set out in people’s plans.

We spoke with a community support worker who was visiting one person at the home. The support worker told us, “We visit regularly to support the person to go to church and maintain local community contacts.”

A relative who was visiting the home told us, “I have seen a real change for the better in my family members’ health and condition since I last came over.”

We saw that people were given support to make choices and decisions for themselves when they needed help to do this, and staff clearly understood each person’s way of communicating their needs and choices.

During the inspection there were 36 people using the service. Due to the complex needs of the people who used the service we were only able to speak with two people. We used other methods to help us during the inspection process. We spoke with two relatives and asked them about the care their family member received. We carried out a tour of the building and reviewed records relevant to the running of the service. We observed staff interaction with people throughout the home. During the inspection we spoke with two care assistants, three domestic assistants, cook, community care nurse, general manager and registered manager.

Throughout this inspection we focused on these five key questions; Is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people who used the service and the staff told us.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

We asked people who used the service and their relatives if they felt their or their family member’s needs were met by the staff and whether they or their family member were safe living at the home. One person who used the service said, “I am safe living here. The staff know what I say is what I want and they respect that.” A relative we spoke with said, “My family member is clean, well presented, not losing weight anymore and taking their medication. They are much safer there than at home.”

Care plans showed there were procedures in place to assist staff should a person experience a seizure as a result of high or low blood glucose levels. These are known as a hypoglycaemic or hyperglycaemic attack.

The home was clean and tidy although there were limited facilities for visitors to wash their hands. Specialised equipment such as wheelchairs and stand aids were stored in a communal toilet which could pose a risk of the spread of infection.

There was not currently an infection control lead within the home and domestic staff did not have a cleaning schedule with them when completing their tasks which could increase the risk of part of their cleaning duties not being completed.

The registered manager showed us the documentation for two people for whom they had applied for a Deprivation of liberty safeguards (DoLS). The paperwork had been completed appropriately. The registered manager also told us they planned to review the current needs of all of the people who used the service to establish whether a DoLS was required for them and submit the relevant applications to the assessing authority where appropriate. Correctly applied DoLS make sure that people in care homes are looked after in a way that does not inappropriately restrict their freedom. The safeguards should ensure that care homes only deprive someone of their liberty in a safe and correct way, and that this is only done when it is in the best interests of the person and there is no other way to look after them.

Is the service effective?

We saw a person had been assessed as posing a risk to their or the safety others due to their challenging behaviour. One to one care had been allocated for this person to reduce this risk. We observed this care throughout the inspection and the staff were effective in ensuring the person received the appropriate support that met their needs.

People received a balanced diet. People’s weight and food and fluid intake was monitored where appropriate. We saw evidence that the home, when required, had appropriately sought advice from a dietician.

Staff received regular assessment of their work. Staff interacted well with people who used the service and were knowledgeable about their needs.

Is the service caring?

The majority of staff provided care in a supportive, safe and caring way. However we did see one member of staff provide a poor level of care. We observed this member of staff transport a person who used the service from one lounge to another in a transportable chair in a way that was inappropriate.

Is the service responsive?

We observed staff respond to people’s needs in a timely manner. We saw people were treated with respect and dignity and staff took time to sit and talk to people.

Where people required further support such as assistance with eating their meals, this was provided. Staff responded to nursing call bells in a timely manner throughout the inspection.

Is the service well-led?

The home has a registered and general manager. The registered manager, who is also a registered nurse, manages the clinical side of the service. The general manager manages other aspects of the service such as the ordering of stock and ensuring staff are appropriately trained.

The registered manager had procedures in place to regularly assess and monitor the quality of the service people received. They liaised on a monthly basis with the local authority providing information to them about the current status of the service.

People’s views were welcomed. A questionnaire for 2014 had been completed and the results were due to be analysed.

The registered manager had identified an area of concern regarding documentation within some care plans. Some care plans did not have the required paperwork regarding a decision not to resuscitate a person. The registered manager was addressing this issue.

People spoke positively about the management team. A person who used the service told us, “The manager is great; they are easy to talk to.” A relative we spoke with said, “The manager is doing a good job.” Another relative said, “I quite like the manager, they were supportive when I needed it.” A staff member said, “Both of the managers are approachable, I have no problem with them.” However another staff member said, “The general manager does not always respond to things as quickly as I would like them to.”