The inspection took place on 14 and 23 March 2018. The first day was unannounced and the second day was announced.

Ashton Cross 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, and both were looked at during this inspection.

Ashton Cross consists of two residential care homes. The Beeches supports up to nine people and the Woodland supports up to six people. On the day of our inspection eight people were living in the Beeches and four people were living in the Woodland. Ashton Cross also supports people living in their own home within the community through their domiciliary care service. There were eight people receiving support at the time of our inspection.

The service has 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 a legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager was absent from the service at the time of our inspection.

At the last inspection in November 2016 we found that some improvements were needed in relation to safe care and treatment. This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Following the last inspection, we asked the registered provider to complete an action plan to show what they would do and by when to improve the key questions of Safe and Well-led to at least Good. The registered provider sent us an action plan that specified how they would meet the requirements of the identified breach. During this inspection we found all required improvements had been made.

This inspection was carried out to check that improvements had been made to meet the legal requirements planned by the registered provider after our comprehensive inspection in November 2016. The team of two inspectors inspected the service against all of the five questions we ask about services: Is the service Safe, Effective, Caring, Responsive and Well-led?

Improvements had been made in relation to people's safety. Window restrictors were now fitted to all required windows to ensure people were not at risk of falling.

Recruitment procedures were safe and robust and sufficient numbers of staff were employed to meet people's individual assessed needs. All staff had completed an induction process and undertaken shadow shifts with experienced members of staff. Mandatory training had been undertaken however, some training required updates.

Staff received regular supervision and support through mentor meetings and also attended team meetings.

The registered provider had comprehensive audit systems in place that had identified areas for development and improvement. The information fed in to quarterly governance meetings.

There were clear safeguarding policies and procedures in place. Staff were knowledgeable and able to describe the process they would follow to raise any concerns. Staff also knew how to raise an alert with the local authority safeguarding team directly.

People's needs had been assessed and this information was used to create comprehensive person centred care plans and risk assessments that were regularly reviewed. People's needs that related to age, disability, religion or other protected characteristics were considered throughout the assessment and care planning process.

People had access to a variety of activities of their choice. The management team had developed relationships with local community organisations.

People received their medicines in accordance with best practice guidelines. Medicines were ordered, stored, administered and disposed of safely. Staff that administered medicines had all received up to date tra

The inspection took place on 17 and 24 November 2016 and was unannounced.

Ashton Cross is part of Transitional Rehabilitation Units (TRU). TRU is a specialist provider offering support and rehabilitation to people following a brain injury.

The service consists of two homes. One home offers communal long term supported living for six people that have completed active rehabilitation but require on-going support. The other home offers a 'home for life' enabling up to nine people to remain as independent as possible. The service has been adapted to support people using a wheelchair.

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.

During our inspection we found a breach of the Health and Social Care Act 2008 (regulated activities) 2014. You can see the action we have asked the registered provider to take at the end of the report.

People were not always protected from harm. Risk assessments were not robust and failed to identify risks to people supported. Window restrictors were not in place to protect people from harm and the front doors of the properties were left open throughout each day of the inspection. This meant uninvited people could enter the properties.

Some of the people who lived at Ashton Cross did not have the ability to make decisions about some parts of their care and support. Staff had an understanding of the systems in place to protect people who could not make decisions and followed the legal requirements outlined in the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS).

Staff had received training in how to recognise and report abuse. Staff were clear about how to report concerns and were confident they would be fully investigated to ensure people were protected.

Staff recruitment procedures were robust, which ensured that appropriate checks were carried out before new staff commenced employment. Staff received a thorough induction and on-going training to ensure they had up to date knowledge and skills to provide the right support and care to people.

People received care and support from regular staff that knew them well and were supported to take their medicines safely.

Care plans provided staff with clear direction and guidance about how to meet individual's needs. This meant people received person centred care. People’s dietary needs and preferences were met and care plans were regularly reviewed.

People were supported to take part in activities and were encouraged to maintain hobbies and interests. This meant people were engaged in regular purposeful activity.

Daily records contained information about how each person’s day was spent. Records included information relating to activities they had completed and any areas of concern as well as therapies undertaken.

People said they would speak to the manager or any staff member if they had any concerns or complaints about the service. People knew how to complain and confirmed when they had raised concerns had been resolved promptly by the registered manager.

There were quality assurance systems in place to make sure that areas of development were identified and addressed. However the audit systems had not identified the areas that required improvement such as the need for window restrictors or an appropriate door entry system.

The registered provider sought feedback from people living at the service and they then used this to develop and shape the service.

We considered our inspection findings to answer questions we always ask;

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well-led?

Below is a summary of what we found at Ashton Cross. The summary is based on our observations during the inspection, speaking with people who used the service, the staff supporting them and from looking at records.

Is the service safe?

People who lived at the home told us they felt safe and were treated with respect. We found there were sufficient members of staff on duty throughout our inspection, to meet the assessed needs of people who lived in the home.

We saw that there was a satisfactory process in place to help protect vulnerable adults from potential abuse. We found that members of staff had received up to date training in safeguarding adults from potential abuse.

We carried out a tour of the premises and saw that the environment maintained the safety of people living in the home, with the provider having made some improvements to the home since our last inspection. We saw that fire extinguishers and portable appliance checks had been carried out and were found to be suitable and safe to use.

In discussion and during observation, we saw that people were relaxed and at ease in their support from staff. People told us they felt safe and content living in the home.

Is the service effective?

The people we spoke with living in the home were complimentary about the service that had been provided. Some of the comments were, “I quite like it here, I like all of the staff as well “and “I get on with most of the coaches (support staff)”.

The members of staff we spoke with had a good understanding of the needs of the people who lived in the home.

We found that people’s health and care needs had been assessed by the service before they went to live at Ashton Cross.

Is the service caring?

During our inspection we observed that staff were attentive, caring and enthusiastic about meeting the needs of people who received a service. We saw people positively responding to members of staff, which helped to demonstrate that good relationships existed between them.

We saw people were treated with dignity and respect by the staff. Some of the staff comments were, “I love working here, wish I had come into this work a long time ago” and “it’s great here. I really like helping people”.

The people we spoke with who lived in the home, said they were happy with the care and support they had received.

Is the service responsive?

Ashton Cross had quality assurance monitoring processes in place. We saw that the provider sought the opinions and views of people who lived in the home and also sought the views of their relatives. There was written evidence that highlighted, when any issues had been identified, the service had responded and addressed them.

We saw evidence that surveys had been distributed to people who lived in the home and their views and opinions had been obtained. Some of the client comments were, “Would like to be treated more normally” and “I would like to go to the cinema more”. No surveys are sent to family members or people’s representatives. The registered manager informed us that the views and opinions of families are obtained at clients reviews, which are held every 12 to 16 weeks.

Is the service well-led?

Ashton Cross had a registered manager who was registered with the Care Quality Commission (CQC) to carry out their role.

In discussion with some members of staff, they said that the manager was approachable and was always willing to listen.

During our inspection of Ashton Cross we spoke with some of the people receiving a service. We observed some interaction between members of staff and people living in the home. The interaction was seen to positive, inclusive and respectful.

Some of the comments from people who lived at Ashton Cross were, “It’s alright here, some good people work here” and “I like living here, always something to do”.

We checked the medication procedures, in order to assess if medicines were correctly and safely administered. At our previous inspection in February 2013 we found this outcome to be non-compliant, judging it to have a minor impact on people living in the home.

We carried out a tour of the home to assess if it was safe, hygienic and comfortable for the people living there and for the members of staff working there.

We looked at the care/support records for three people living at Ashton Cross.

We checked the staffing rota lists for the previous month. This was to determine if the home was adequately staffed, to meet people's needs.

We looked at the homes records including, health and safety records, audits (checks) of quality assurance systems. This was to identify that people's care records and records pertaining to the safety and wellbeing of people who lived in the home, were appropriately maintained and secure.

Ashton Cross provided rehabilitation care pathways for people with acquired brain injuries. Care pathways were formulated to achieve the best possible goals for each individual, their families or carers.

The aim of the service was to support people to live as independently as possible whilst living at Ashton Cross. Daily progress records documented each person's proposed programme of care and rehabilitation tasks. Activities of daily living were documented. General health needs were documented within a nursing summary. Assessments included nutrition, mobility, swimming and attendance at the gym. Physical exercise was encouraged.

We spoke with two people who used the service. Comments included "It's great here, I am happy here", "The staff here are brilliant, I owe a lot to the staff here, they really look after me", "I am able to do much more now since I have been living here".

We sampled four personal files of care staff during the inspection. We found that files contained the required information to demonstrate that staff were safely and effectively recruited and employed.

There was a system in place to monitor the quality of the service provided at Ashton Cross. We sampled three provider monitoring reports from October to December 2012. We noted no concerns had been identified.

People using the service told us:

"when someone mentions rehab, you initially think of bars on windows etc, it's not like that at all",

"I am on initial assessment (period of 16 weeks) It gives an opportunity for me to get some form of a job",

"They (TRU) have set up a private tutor for me","I can't fault anything here",

"I have been to a lot of head injury places all were good, but not a patch on here",

"It's amazing here, it's just an opportunity that can't be missed",

"It's a wonderful place","It's the best,no problems at all" and "the staff are brilliant, always doing things for your best interest".