This comprehensive inspection took place on 20 and 21 March 2018. The first day was unannounced. This meant the provider did not know we would be visiting the home on this day.

Ashton View 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; both were looked at during this inspection.

Ashton View is in Ashton-in-Makerfield and is part of HC-One. The home provides residential and nursing care as well as care for people living with dementia. The home provides single occupancy rooms, across three units, which are known internally as Evans (general nursing), Gerard (providing nursing care for people living with dementia) and Pilling (residential). At the time of the inspection there were 52 people living at the home.

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.

At the last inspection carried out on 10 May 2017 we found seven breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were relating to regulation 12; safe care and treatment (two parts), regulation 13; safeguarding service users from abuse and improper treatment (two parts), regulation 14; meeting nutritional and hydration needs and regulation 17; governance (two parts). We also made three recommendations in relation to reviewing the dependency tool used to calculate staffing levels, the environment and activities.

Following this inspection we asked the provider to complete an action plan to show what they would do and by when to improve the overall rating to at least good.

At this inspection we found the provider had taken remedial action and was no longer in breach of the parts of these regulations.

However we found during this most recent inspection the service was in breach of two different regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were relating to Person centred Care and Good Governance. You can see what action we told the provider to take at the back of the full version of this report.

People were not always receiving support in line with their care plans and some people’s files did not contain any historical information including likes and dislikes.

The service had been subject to an electrical installation audit in May 2017 where multiple improvements were required, however, ten months later some of these tasks were still outstanding.

Staff received adequate training and supervision support from the provider and were knowledgeable about the people they supported. This was also confirmed by people’s comments during the inspection; people told us they felt staff were competent and well trained.

People's care files contained information in relation to their dietary requirements, skin integrity, falls management and further perceived risks associated with daily living tasks.

Environmental risk assessments were in place for both internal and external areas and the provider employed a maintenance team to oversee daily internal and external maintenance issues.

Safeguarding policies and procedures were in place to ensure people, staff and visitors were aware how to raise concerns and what abusive practice looks like. Staff received training in this area and a record of safeguarding referrals was kept securely.

Safe recruitment procedures were adhered to and the provider ensured new staff received a period of induction before being assessed as competent to work alone.

Risk assessments were in place in each person's file we looked at to manage identified risks associated with daily living and also

This comprehensive inspection was unannounced and took place on 10 May 2017.

At our inspection on 22 October 2015, we found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The breaches were in regards to safe care and treatment and governance.

The home was rated as requires improvement overall and in the key lines of enquiry (KLOEs) for; safe, effective and well-led. The home was rated as good in caring and responsive.

At this inspection we found seven breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in regards to regulation 12; safe care and treatment (two parts), regulation 13; safeguarding service users from abuse and improper treatment (two parts), regulation 14; meeting nutritional and hydration needs and regulation 17; governance (two parts). We also made three recommendations in relation to reviewing the dependency tool used to calculate staffing, the environment and activities. We served a warning notice in regards to regulation 17; good governance (two parts) and received an action plan from the registered provider detailing how the areas of concern would be addressed to ensure the home was compliant with the regulations.

Ashton View is in Ashton-in-Makerfield and is part of HC-One. The home provides residential and nursing care as well as care for people living with dementia. The home provides single occupancy rooms, across three units, which are known internally as Evans (general nursing), Gerard (providing nursing care for people living with dementia) and Pilling (residential). At the time of the inspection there were 53 people living at the home.

At the time of the inspection, there was no registered manager in post. The home’s registered manager had left in April 2017 and a regional support manager from HC-one was providing daily oversight and management whilst recruitment was underway for a new 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.

The regional support manager was on leave when we undertook the inspection and management oversight was being provided by another manager from within HC-One. The interim manager had only been post for two days prior to our visit and acknowledged they were unable to answer some of our historical enquiries as they had not been present at the home during that period.

People who used the service and the majority of relatives told us they felt the service was safe. Staff recruitment was robust with appropriate checks undertaken before staff started working at the home.

We received a mixed response from people living at the home, staff and visiting relatives with regards to staffing levels at the home. Whilst a formal dependency tool was used to determine staffing numbers and staff said they felt people’s care needs were not compromised as a result of current staff numbers, they reported feeling rushed and unable to spend time with people. We have made a recommendation with regards to staffing levels in the detailed findings of this report.

We found staff received online safeguarding training but staff indicated they would benefit from face to face training in this area. We found two specific incidents which involved a person living at the home that had not been reported to the local authority for investigation.

We identified issues with the management of stock levels and re-ordering of medicines, which meant people had missed doses of medicine until new supplies arrived. We also identified some issues with the recording of as required medicines (PRN) to establish a clinical picture.

The service had a training matrix to monitor the training requirements of staff. Staff received app

This comprehensive inspection was unannounced and took place on 22 October 2015.

We last inspected this home on 07 August 2014, when we found the service to be compliant with all regulations we assessed at that time.

Ashton View is in Ashton-in-Makerfield and is part of HC-One. The home provides residential and nursing care as well as care for people living with Dementia. The home provides single occupancy rooms, across three units, which are known internally as Evans (general nursing), Gerard (providing nursing care for people living with dementia) and Pilling (residential). At the time of the inspection there were 57 people living at the home, across the three units

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 2008 and associated Regulations about how the service is run.

During this inspection we found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

During the inspection we checked to see how the service managed and administered medication safely. We found people were not always protected against the risks associated with medicines, because the provider did not have appropriate arrangements in place to manage medicines safely.

We found that a number of records we looked at were prescribed at least one medicine to be taken ‘when required.’ We found that all medicines prescribed in that way did not have adequate information available to guide staff on to how to give them. We found there was no information recorded to guide staff on which dose to give when a variable dose was prescribed. It was important this information was recorded to ensure people were given their medicines safely and consistently at all times.

We found two instances were PRN medicines had run out for people who used the service and in one of these instances the person had required the medication and been unable to be given it due to it not being available. We found that the registered manager had not protected people against the risk of associated with the safe management of medication. This was in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, safe care and treatment.

People felt safe in the home and relatives said that they had no concerns. However, people did raise concerns about staffing levels and that there was not enough staff to meet people’s needs. We made a recommendation that the registered manager employs a dependency tool based upon the needs of the people using the service to ensure that there are sufficient, effectively deployed staff to meet those needs.

Staff understood the need to protect people from harm and abuse and knew what action they should take if they had any concerns.

Effective recruitment procedures were in place. Each personnel file had a completed application form listing their work history as wells as their skills and qualifications. Nurses employed to work in Evans and Gerard unit all had registration with the nursing midwifery council (NMC) which was up to date. Training schedules confirmed staff’s training was up to date and staff received supervision, however we found that this was not always conducted in the time frame specified and appraisals had not been undertaken.

Everyone we spoke with was happy with the food provided and people were supported to eat and drink enough to meet their nutritional and hydration needs. Any dietary requirements were catered for and people were given regular choice on what they wished to eat and drink. Risk of malnourishment was assessed and acted upon.

People and their relatives were actively involved in decisions about their care. There were formal systems in place to assess people’s capacity for decision making under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS).

We observed across the three units that a lot of people were either living with memory issues or dementia. We found the home did not have adequate signage features that would help to orientate people with this type of need. We saw no evidence of dementia friendly resources or adaptations in any of the communal lounges, dining room or bedrooms. This resulted in lost opportunities to stimulate people as well as aiding individuals to orientate themselves within the building. We have made a recommendation in relation to environments.

Staff members had a good understanding of people’s personal history, likes, dislikes and personality traits. It was clear staff had spent time building rapports with people. Staff interacted with people in a kind and friendly manner and people appeared at ease in the company of staff. People and their relatives spoke highly of the caring nature of staff. One person told us, “The staff are very good, kind and caring.”

We found that one person had pressure ulcers and although we saw evidence that they had been referred to the tissue viability nurse (TVN), this had not been followed up resulting in a further skin breakdown and a significant delay to this person receiving professional assessment and treatment. This was in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, safe care and treatment.

People were encouraged and supported to engage in activities and events that gave them an opportunity to socialise. Staff ensured people obtained advice and support from other health professionals to maintain and improve their health.

Feedback had been sought from people, relatives and staff. Resident and staff meetings were held on a regular basis which provided a forum for people to raise concerns and discuss ideas. Incidents and accidents were recorded, but not consistently investigated and disseminated.

The provider and registered manager undertook quality assurance reviews to measure and monitor the standard of the service and drive improvement. Although there were systems to assess the quality of the service, we found that areas that had been identified at the provider audit had not consistently been actioned which meant that people had been exposed to continued risks to their health, wellbeing and safety. This was in breach of regulation 17(1)(2)(a)(b) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The registered manager was visible and accessible and staff and people had confidence in the way the home was run.

This is a summary of what we found.

Is the service safe?

Both the people who lived in the home and their relatives were pleased with the care provided and felt that their views were respected and listened to. The staff worked in a safe and hygienic way and used appropriate protective clothing. Some of the staff and relatives we spoke with felt there was not enough staff to meet the needs of the people living in the home. The registered manager said that staffing levels were adequate during the day but she deliberately overstaffed the rota for the night shift. A member of the management team was available on call in case of emergencies. One relative said: “There is a good feeling. He’s so safe.”

The registered manager and the staff we spoke with understood the importance of safeguarding vulnerable adults,could identify potential abuse and knew how to report any incidents of abuse.

Is the service effective?

People told us that they were happy with the care that had been delivered. A person who lived in the home said: “They look after you well.” Another person said: “I have no complaints whatever.”

Care records confirmed people’s preferences, interests and needs had been recorded and care and support had been provided in accordance with people’s wishes. One person said: “It is wonderful. I am so relaxed.”

We heard that information was shared very effectively between staff. Several ways of sharing information included handovers, daily records, and monthly reviews with relatives.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and encouragement when supporting people. One relative said: “My mum is settled here. They care for her as much as they can do.” One person who used the service said: “Everyone is so kind.”

Is the service responsive?

People’s needs had been assessed before they were admitted to the home. Their needs were carefully described so that care workers knew exactly what tasks to undertake to support them. Changes in people's care needs were reported to the nurse team leaders and they briefed care staff at handovers and via the updated care plans.

One relative said “They know that if there’s anything wrong I want contact.” They also commented that the district nurse visited regularly, a doctor called as did an advanced nurse practitioner. They felt their relative was receiving good care from the team.

Is the service well-led?

Staff had a good understanding of the culture of the home and quality assurance processes were in place. People told us they had received customer satisfaction surveys and that staff listened to their concerns. The manager met informally with families and we saw an invitation to the next meeting in the reception area. The manager was also available whenever they visited. Staff told us they were clear about their roles and responsibilities and said : “ She (the manager) is easily approachable.”

We used a number of different methods to help us understand the experiences of people using the service, because some of the people using the service had complex needs which meant they were not able to tell us their experiences.

During our visit we met with eleven of the people living at Ashton View Care Home and seven of their relatives. We also met with other people living there and observed the support provided to them.

In addition we spoke with fourteen members of staff who held various roles within the home.

Relatives told us that in their opinion people had received the support they needed with their personal care. They said that staffing levels were adequate but felt the home would benefit from having more staff members especially on Evans unit.

People told us they were happy with the services but wished that there were more staff around to assist them. They said staff worked very hard but were not always able to provide support when it was required. One person told us that staff were wonderful but could only do so much as a lot of people had high levels of support needs. A visiting relative told us that they assisted to feed their relative as they were fully aware of the pressures on staff to provide care and support to many vulnerable people.

The people using the service who were able to tell us said that they were happy living in the home. Comments included; ‘I am fine’, ‘I am very happy here” “I want to live here forever”, ‘This is a nice place to live,” Staff are kind and I love it here’. ‘The staff are good’, “Staff are kind and helpful”, “Staff assist me when I need help”.

Relatives of people living in the home told us that they felt staff treated people with respect and made sure people got the social, health care and reassurance they needed. They said staff were very supportive and helped people to get the most out of life.

One person said that since her mother had moved into the home she had seen very positive changes in her attitude and general wellbeing. She said this was thanks to the staff for their care and attention.

People told us the staff were kind and helpful and were able to provide a good level of care and support

Relatives of people living in the home said staff speak with them on a regular basis to ask their perceptions of how the home is run.