We previously carried out an unannounced comprehensive inspection of this service on 8 and 20 July 2017. At that time Ashlyn was rated ‘Inadequate’ due to insufficient staffing levels, the provision of unsafe care and treatment, poor risk management and a lack of person-centred care which meant that people’s preferences were not known or upheld. We also found a lack of leadership and oversight of the quality and safety of the service. During the inspection of July 2017 we found breaches of Regulation 9, 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Due to the high level of concerns regarding the breach of Regulation 9 (person-centred care) we served the Provider with a Warning Notice. This document set out where the service was failing and required the provider to address our concerns within a specific time frame. As a result of our inspection the service was placed in special measures. The purpose of special measures is to ensure that providers found to be providing inadequate care significantly improve within a set timeframe.

Following our inspection and subsequent enforcement action, the provider supplied us with an action plan, which set out what they would do to meet the legal requirements in relation to the breaches and to improve the service. We then undertook a further comprehensive inspection to check that the service had implemented their action plan and to confirm that they now met the legal requirements. At this inspection we found that the service had followed its plan to address the breaches and those aspects of the service that required improvement which meant that the service now met the legal requirements and was no longer in breach of the regulations.

The inspection took place during the day and into the evening of 19 March 2018 and was unannounced.

Ashlyn 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 care home accommodates 60 people in one building, over two floors. At the time of our inspection there were 40 people living at the service some of whom were living with dementia.

Since the previous inspection the provider had recruited a new manager who was going through the process of applying to become the 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.

Significant improvements had been made in terms of oversight of the service at both manager and provider level. Quality assurance mechanisms were now in place which were effective at identifying and addressing areas of the service that required improvement. A new style of leadership had been adopted by the new manager which reflected a more ‘hands-on’ approach. The visibility and approachability of the new manager had improved staff morale and the staff reported that they now felt listened to and supported. This had a knock on effect on people who lived at the service who reported that there was a much nicer atmosphere in their home.

The new manager had made a positive impact on the culture of the service. Teamwork had improved and staff felt valued. The manager was a role model for staff and promoted the vision and values of the service which included putting the needs of people first and treating people as individuals.

Staffing numbers had been increased and systems and processes for care recording had been streamlined which meant staff had more time to spend with people and could safely meet their needs. Improvements in staffing levels and how staff were deployed also meant that people’s routines a

We previously carried out an unannounced comprehensive inspection of this service on 22 April 2016. At that time Ashlyn was awarded a rating of 'Good' overall but was rated 'requires improvement' in the domain of safe due to concerns expressed by people and relatives regarding low staff numbers. Following on from that inspection we subsequently received concerns in relation to insufficient staffing and safe care and treatment of people. We therefore undertook an unannounced night inspection on 8 July 2017.

During this inspection visit we found breaches of our regulatory requirements and as a result of our concerns we wrote an urgent action letter to the provider requesting an action plan to set out how they would deal with the issues we found. We then completed an unannounced follow up visit on 20 July 2017 to complete a comprehensive inspection of the service.

During our inspection we found breaches of Regulation 9, 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what actions we told the provider to take at the back of the full version of the report.

Due to the high level of concerns regarding the breach of Regulation 9 relating to person-centred care, specifically that people were not receiving regular baths or showers in accordance with their expressed needs and preferences. We served the registered manager and provider with a Warning Notice. This set out where the service was failing and required the provider to address our concerns within a specific time frame.

The overall rating for this provider is 'Inadequate'. This means that it has been placed into 'Special measures' by the Care Quality Commission. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains 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 the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action.

Ashlyn is a residential care home registered to provide accommodation and personal care for up to 60 people. At the time of our inspection visits 51 people were using the service, accommodated on two floors. The ground floor was residential whilst the first floor was occupied by people living with dementia.

There was a registered manager in post. 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. We were advised that the registered manager intended to resign and that the deputy manager would be taking over as registered manager in the near future.

The service was failing to provide person-centred care, particularly with regard to supporting people with their personal care and respecting people’s preferences around bathing. The care and support people received was task-focussed which met the needs of the service rather than the needs of people. The system employed by the provider to deliver bathing support to people desi

The inspection took place on 22nd April 2016. Ashlyn is a residential care home providing care and accommodation for older adults some of whom are living with dementia. There are currently 54 people who use the service.

The service has a registered manager in post. 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.

We found that risks were not always well managed due to poor or inconsistent recording practices.

On the day of inspection we saw there were sufficient, suitably recruited staff employed to keep people safe. However people and staff reported that this was not always the case. The registered manager advised us that steps had already been taken to address the shortfall and new staff had been recruited.

The provider had suitable arrangements in place for the management of medicines and people received their medicines safely.

People were protected from abuse as staff knew what constituted abuse and who to report it to if they suspected it had taken place.

The Mental Capacity Act 2005 (MCA) is designed to protect people who cannot make decisions for themselves or lack the mental capacity to do so. The Deprivation of Liberty Safeguards (DoLS) are part of the MCA. They aim to make sure that people in care homes, hospitals and supported living are looked after in a way that does not inappropriately restrict their freedom. The provider followed the principles of the MCA by ensuring that people consented to their care or were supported by representatives to make decisions.

Staff were supported to carry out their role effectively. A system to provide regular supervisions and appraisals was in place and there was a regular programme of training with opportunities planned for specialist training relevant to meeting the needs of the people using the service.

People were supported to have enough to eat and drink and to access health care services to maintain their health and wellbeing. When people became unwell staff sought the appropriate support.

Care workers had positive relationships with people who used the services. Care was personalised and met people's individual needs and preferences.

People, or their representatives, where appropriate, were involved in making decisions about their care and support and felt listened to and included.

Care workers treated people with dignity and respect and promoted people’s independence.

People were supported to maintain relationships that were important to them. Staff interacted with people, supporting them to engage in activities of their choice.

The provider had a complaints procedure in place and people who used the service knew how to use it. People’s concerns and complaints were listened to and addressed in a timely manner.

Staff told us that they were well supported by the management team and felt confident that any concerns they raised would be listened to and dealt with fairly.

The provider had systems in place to monitor the quality of the service and this was used constructively to drive improvements.

The inspection team consisted of two inspectors. We set out to answer our five questions; is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection visit, discussions with people using the service, their relatives, the staff supporting them and visiting professional staff.

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

Is the service safe?

People told us they felt safe and on the whole relatives were very happy with the quality of care provided by staff to their family member. Care plans we reviewed, had evidence of good assessments of people's needs being carried out with risks to people's welfare identified and plans put in place to minimise these.

Systems were in place to make sure staff were trained and supported to carry out their roles with audits undertaken of their care practice and development plans instituted when required.

There was an electronic care record system which included incident and accident reporting, and we observed evidence of the service's learning from accidents, incidents, complaints and concerns.

Is the service effective?

People's health and care needs were assessed though they were not always aware of what was in their care plans. Their care also involved the input of other professionals such as district nurses, GPs and community matrons where this was required, for example when dressing people's wounds and ulcers.

We spoke with visiting health care professionals who informed us they were happy with the care provided and that staff asked for, and took, professional advice to inform people's care plans.

There was good signage around the home to help people with memory problems find their way about, including their names on their bedroom doors. Some concerns had been raised in surveys and complaints about staffing levels, however, on the day of our visit care staff were observed interacting with people in communal areas as well as in one to one care.

One relative told us they had made a complaint about the levels of staffing over a year ago, however, was much happier with the present levels. They told us, ''I won't sit back if I have concerns but I believe issues will be dealt with.''

Is the service caring?

We spoke to people who used the service about their opinions of the care staff. One person told us, ''The staff are great, they are like my friends, we are all friends here.'' Another person said, ''Most of the staff are lovely, I can't fault them.''

There was a homely atmosphere around the home and whilst observing at lunchtime, we noted staff assisting with cutting of food and feeding people where they needed help. People were cared for by kind and attentive staff who showed patience and used non verbal communications to support people.

Many positive interactions were noted, as well as banter and joking between people who used the service and the care staff.

Is the service responsive?

There was a well- advertised complaints number for people to ring and visitors' feedback forms for people to complete if they wanted to raise any issues. The home carried out a regular monthly survey for people who lived there, relatives and visiting professionals in order to seek their views about the service provided. Any issues raised were discussed with the staff team and addressed and monitored.

We spoke to relatives and one told us about a complaint they had made and how it had been dealt with effectively.

During our visit we spoke to a district nurse who told us that any suggestion she had offered, for example people having their own sliding sheets, had been acted on by staff.

We were also told by staff during discussions that they used to work on both the upstairs and downstairs units. However, this had been changed to provide regular staffing on the dementia unit to minimise the confusion of those people living there.

Is the service well led?

The service had robust quality monitoring systems in place and there was evidence of changes taking place to better meet residents needs, for example more consistent staff team to work with people on the dementia unit.

All staff had access to training courses and ongoing development, as well as regular supervision and appraisal of their working practices.

Managers organised regular relatives meetings though we noted the previous one had been cancelled due to lack of attendance. These meetings were advertised on the noticeboard in the entrance to the home so that people knew in advance when they were going to take place.

The service linked into its wider management system and on the day of our visit we met the regional manager and the development manager, both of whom carried out auditing and monitoring roles to ensure the standards in the home were maintained.

The visiting professionals we met were confident that managers would listen to and act on advice or concerns raised.

We saw that there was a detailed assessment of people’s needs before they came to live at the service. Relevant risk assessments and control measures were referenced throughout the care plans to ensure continued care. This meant that the delivery of care met all of the person’s needs.

Steps were taken to enable people who used the service to obtain appropriate support. The district nurse that we spoke with told us, "If there's something wrong with someone here they're very good at getting us in. They're quite on the ball; any sores they do call us right away or the GP if the patient needs to see a GP."

We found that the provider had suitable arrangements in place to safeguard people from the risk of abuse.

There was an effective system in place to detect and control the spread of infection. One member of staff told us, "When there's an infection, nothing comes out of the room unless it's bagged up and goes straight into the yellow bin." One relative told us, "It's spotless."

We found the premises to be of a suitable design and layout. A relative that we spoke with told us, "I think it's a beautiful home. I can't knock it at all."

We carried out an inspection following receipt of a communication that raised concerns about the way the service was delivered. We received information that the home had insufficient numbers of hoists to assist people with mobility difficulties who lived on both the ground and first floors of the home. The manager told us that there was one standing hoist and one full body hoist at the home.The manager told us that six people needed assistance to be moved with a hoist and it was therefore judged that the two hoists were sufficient for this purpose.

We also received information that there were insufficient staff members to care for people who lived at the home. The manager told us that 53 people lived at the home at the time of the inspection. We looked at the staff rotas that showed that during the day there were two senior and seven care workers on duty. People told us that staff came quickly if they needed them. We judged that there were sufficient staff to care for people.

We looked at the five complaints that had been received since our last inspection in November 2012. We saw that for each complaint that had been received a full investigation had been carried out. A full response was sent to the person who made the complaint.

People told us that they were happy living in Ashlyn. They felt that most of the staff were caring and able to meet their needs. People said that staff were generally available when they needed them, but they might have to wait a while for help at busy times. One person felt that this could sometimes be difficult, particularly when they needed to use the toilet and had to wait.

People said that they were given choice about how they spent their time and that activity and occupation were generally available to them.

People said that they liked their rooms and were happy with the food provided.

We used a number of different methods to help us understand the experiences of people using the service, because many of the people using the service had complex needs which meant they were not able to tell us their experiences. One person told us, “I can say what I want. It’s very good here.” Another person said, “It’s like a holiday camp, marvellous.”

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. We observed how staff interacted with people in the period before and during lunch. The people we observed were alert and interested, and staff spoke with them and engaged them in conversation. We observed care workers taking time to talk patiently with people, following the guidance in their care plan.

People were provided with a choice of suitable and nutritious food and drink. However we observed staff putting plated meals on the table without explaining to people what the meal was. One person told us, “I had soup, but I don’t know what sort of soup it was.”

We saw evidence of assessments of people’s capacity to take decisions. There were several assessments of capacity in place for one person for separate decisions about their care and their environment. In each of these the person was assessed to not have capacity to understand the situation, and a decision was made in their best interests by people concerned with their welfare.