This unannounced comprehensive inspection was carried out on 25 July 2018.

Ashwood - Ware 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. Ashwood - Ware is a purpose-built care home and is registered to provide accommodation and personal care for up 64 older people some of whom are living with dementia. At the time of our inspection 53 people were living at Ashwood - Ware.

The home is built on a single level with wide corridors connecting the bungalows together. There were three enclosed garden areas for people to access outside space freely.

During our last comprehensive inspection on 13 July 2017 we identified breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 relating to safeguarding, risk assessment and governance. We rated the service requires improvement. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the five key questions to at least good. At this inspection we found that all the areas we previously found not meeting the required standards were improved. People received care which was safe and met their individual needs.

There was a manager in post who had registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the CQC 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 and associated Regulations about how the service is run.

People and relatives, we spoke with told us they felt safe at the home. People`s needs were met by staff who knew them well and provided care and support to people in a personalised way.

People and staff told us they felt it was enough staff at all times to meet people`s needs in an effective and timely way. People`s privacy and dignity was promoted.

Risks to people`s wellbeing were assessed and plans were in place with clear guidance for staff to know how to keep people safe.

Staff knew how to protect people from the risk of abuse and promptly reported to the registered manager if they had any concerns about people`s welfare.

People received their medicines safely from staff who were trained and had their competencies assessed in the workplace.

Staff told us they received sufficient training to help them understand their role and they received support from their managers to carry out their responsibilities well.

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 support this practice.

Care plans were developed and personalised to ensure that staff were able to deliver care and support according to peoples` preferences, likes and dislikes.

People were supported to pursue their hobbies and interests and they were encouraged to participate in social activities.

People told us they were happy with the quality of the food they received and that drinks and snacks were widely available throughout the day.

The register manager was known to people and relatives. They worked alternate weekends with the deputy manager to ensure management support was available to people and staff over Saturdays and Sundays.

The providers systems and processes were effectively used by the registered manager to identify areas where the service needed improvement and we found that actions resulting from audits were addressed in a timely way.

Ashwood is a purpose built care home and is registered to provide accommodation and personal care for up 64 older people some of whom are living with dementia. At the time of our inspection 60 people were living at Ashwood.

The home had a registered manager in post who left the service one week prior the inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 time of the inspection the home was managed by an interim manager who told us they will be registering with CQC shortly.

The inspection took place on 13 July 2017 and was unannounced. When we carried out an unannounced comprehensive inspection in Ashwood on 27 July 2016 we found that the service required improvement in some areas which included incidents not being sufficiently identified and reviewed to ensure people were kept safe. Systems and processes for monitoring and reviewing the service were not consistently effective. We undertook a focused inspection on 13 April 2017 in response to concerns raised to us about lack of staffing in Ashwood. During this inspection we identified breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 relating to keeping people safe, medicines management, staffing and governance.

At this inspection we found that some improvements were made around medicine management and staffing however the change in management had slowed the process and further improvements were needed to ensure people living in Ashwood received safe and quality care.

Risks to people`s well-being were identified and assessed, however actions were not always in place or followed by staff to help ensure risks were sufficiently mitigated to keep people safe.

Where people sustained unexplained bruises, these were documented, however were not investigated or reported to local safeguarding authorities.

Although the environment in Ashwood was newly decorated and looked fresh there were persistent odours around the home throughout the day and by the afternoon some people had unpleasant odours around them.

Governance systems and people`s care records continued to be an area in need of improvement. The interim manager and the provider told us they identified and were working on improving the quality of the governance systems used, updating care plans and building a permanent staff group.

People and staff told us that staffing had improved and their needs were met in a more timely way, however at times we saw that staff were under pressure especially during busy times in the morning to meet people`s needs.

People`s medicines were managed safely by trained staff who had their competencies checked regularly.

Staff felt supported by the interim manager who enabled them to carry out their role effectively. Staff had received training relevant to their role and were offered the opportunity to develop their skills and progress in their career.

People’s consent was sought prior to care being carried out and staff took time to explain the task they wished to carry out. People's nutritional needs were met and their food and fluid intake and weight were monitored, although not always documented. People were able to choose what they ate from a varied menu and the provider was working to further improve this area so people had more choices at breakfast time. People`s health needs were met and they had access to a range of health professionals when needed.

Staff spoke with people in a kind, patient and friendly way and respected people`s privacy. People felt listened to and told us they felt the home has improved since our last inspection. Staff were aware of people’s needs, choices and we saw that a friendly rapport had developed between peop

We carried out an unannounced comprehensive inspection in Ashwood on 27 July 2016. We found that the service required improvement in some areas which included incidents not being sufficiently identified and reviewed to ensure people were kept safe and systems and processes for monitoring and reviewing the service were not consistently effective.

We undertook a focused inspection on 13 April 2017 in response to concerns raised to us about lack of staffing in Ashwood. During this inspection we identified breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 relating to keeping people safe, medicines management, staffing and governance.

Ashwood is a purpose built care home and is registered to provide accommodation and personal care for up 64 older people some of whom are living with dementia. At the time of our inspection 60 people were living at Ashwood.

The home had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

People were not supported by sufficient numbers of staff. As a result people experienced delays in having their needs met and the care and support they received was not always personalised.

People had their needs assessed and risks involved in their daily living were identified, however risk assessments were not reviewed every time people`s needs changed and there was not always sufficient guidance for staff in how to manage risks and keep people safe. People's medicines were not consistently managed safely. People`s records containing personal and confidential information were not always kept securely.

People`s lives were potentially at risk in the case of a fire. An independent fire safety audit carried out in January 2017 highlighted several faults around the home and the registered manager was unable to evidence that they have reported these to the provider or that the faults had been corrected.

The registered manager had been in post since December 2016. They had previously worked at the home however in a different role. People and staff told us they were unsettled by the management changes and also they found it difficult to adapt to the registered manager`s ways of working. Staff told us they didn’t feel supported by the registered manager and they were not listened to.

Governance systems used by the registered manager to measure the quality of the care they delivered were not effective in highlighting areas where there was a need for improvement. Policies and procedures which had a direct impact on the safety of the environment and care were not reviewed by the registered manager and they were still signed by the previous manager.

We found the provider to be in breach of regulation 12, 18 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The actions we told the provider to take are listed at the back of the report.

Ashwood is a purpose built care home and is registered to provide accommodation and personal care for up 64 older people some of whom are living with dementia. At the time of our inspection 61 people were living at Ashwood.

The home had a registered manager in post who had been registered since October 2010. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 inspection took place on 27 July 2016. We arrived early in the morning to inspect the service which was unannounced. At our previous inspection on 23 and 25 September 2015 we found breaches of regulations 09, 10, 13, 14, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because people were not supported by sufficient numbers of suitably trained and skilled staff. People's nutritional and care needs were not met and responded to safely. When staff identified people`s changing needs management did not respond in a timely way to put measures in to keep people safe. We also found that people were not treated in a dignified manner, people's care records were out of date and staff were not aware of people's needs. Governance systems were not robust to allow management to sufficiently review, monitor and respond to identified concerns and staff did not feel supported by the management team or provider.

At this inspection we found significant improvements had been made in areas relating to safe care and treatment, staffing levels, supporting staff, treating people with dignity, and communicating with people and relatives. However we also found improvements were still required in governance systems to ensure the service was well led and records relating to people's care were accurate.

People were supported by sufficient numbers of staff who responded promptly when they required assistance. Staff we spoke with were knowledgeable in relation to keeping people safe from harm and reporting incidents to management, however these were not always identified or investigated and responded to quickly. Staff we spoke with were aware of people's current needs and how to keep people safe from the risk of harm.. People's medicines were not consistently managed safely and we found an incident where one person had not received their medicines as intended by the prescriber.

Staff felt supported by the manager who enabled them to carry out their role effectively. Staff had received training relevant to their role and were offered the opportunity to develop their skills and progress in their career. People’s consent was sought prior to care being carried out and staff took time to explain the task they wished to carry out. People's nutritional needs were met and their food and fluid intake and weight were monitored, although not always documented. People were able to choose what they ate from a varied menu. People`s health needs were met and they had access to a range of health professionals when needed.

Staff spoke with people in a kind, patient and friendly way and respected peoples dignity. People felt listened to and told us they felt they could shape their own care to reflect their own personalised choices. Staff were aware of people’s needs, choices and we saw that a friendly rapport had developed between people and staff who cared for them.

Governance systems and updates in people`s care records continued to be an area that was under development, however the registered manager was able to demonstrate to us how they were addressing these issues. People were positive about the management team and told us that significant improvements had been made across the home by the management team and the provider.

We previously inspected Ashwood on 11 September 2013 and found there were not sufficient staff to support people's needs. We also found senior staff were not always able to provide support to carers as appropriate. However, we found during an inspection on 09 December that improvements had been made. One person who used the service told us, “The staff could not be more attentive to me, I get what I need when I need it.”

We found that before people received any care they were asked if they were happy for this to be given. One person who used the service told us, “They always ask me if it is okay before they do anything, even down to what I would like for supper.”

People told us they were happy with the care and treatment they received at Ashwood care home. We noted that care was planned, reviewed and delivered in a person centred manner. One person told us, "The care here is tip top, it's lovely and I have everything I could ever need."

People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

We found that staffing levels were not determined by the individual needs of people who used the service at that time. During busy periods, such as in the morning when staff were busy assisting people, we found that people who used the service would need to wait to be supported in a manner that was undignified. Staff were working longer hours than they were contracted for in order to ensure records were accurate and care was delivered. One person told us, “Sometimes the staff just don’t get here when I need some help, other than that they are a fantastic bunch.”

We found that the home had a range of audits in place to measure the safety and effectiveness of care given to people. The manager took account of, and responded to, concerns or suggestions from people or their relatives.

During inspections carried out on 11 July 2012 we found that people were not protected from the risks of inadequate nutrition and hydration and their dignity was not respected.

The provider sent us an improvement plan in August 2012 to tell us the actions they had taken, or were to take, to address this and achieve compliance.

Our inspection on 15 February showed that people’s dignity was respected and the risk of inadequate nutrition was minimised.

We spoke with five people who use the service, checked records of manager’s audits of meal times, spoke to three staff and observed lunch time. We noted that people were treated with respect and that one–to-one help was introduced at meal times. We also saw that people were appropriately addressed, spoken with and helped by the sufficient number of staff in all three dining rooms that we observed.

The provider had changed their fresh meat supplier which improved the quality of meat. This improved the quality of food served and enabled some people to remain independent. We saw a person who was unable to cut their meat during the inspection on 11 July 2012 and saw how they cut their meat during the inspection on 15 February. We observed that staff supported two people on a one-to-one principle to eat, without rushing them. This showed that the improvement actions implemented by the provider worked and improved the quality of service to people who used the service.

People told us what it was like to live at this home and described how they were

treated by staff and their involvement in making choices about their care. They

also told us about the quality and choice of food and drink available. This was

because this inspection was part of a themed inspection programme to assess

whether older people living in care homes are treated with dignity and respect

and whether their nutritional needs are met.

The inspection team was led by a Care Quality Commission (CQC) inspector

joined by an Expert by Experience who has personal experience of using or

caring for someone who uses this type of service.

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.

People we spoke with felt that their personal care was carried out in a way which maintained their privacy and dignity. We observed that staff were polite and courteous to people and offered them choices about their day to day routines.

During our inspection visit to Ashwood we spoke with four people using the service and three visitors. Everyone said that people were treated in a respectful and dignified manner although one person said, “Staff shortages can mean that sometimes care is rushed and some staff can be abrupt.”

People told us that they could choose where they wanted to eat their meals, they told us that they had a good choice of food and snacks available on request.

Relatives told us that they were welcome to visit at any time of the day or night and were always made to feel welcome by staff.

Ashwood is a purpose built care home and is registered to provide accommodation and personal care for up 64 older people some of whom are living with dementia. At the time of our inspection 64 people were living at Ashwood.

The inspection took place on 23 and 25 September 2015. On the 25 we arrived early in the morning to inspect the service. Both days of the inspection were unannounced. We previously inspected Ashwood – Ware in December 2013. During this inspection we found that the provider had taken action to improve staffing levels at the home and was at that time meeting the required standards.

The home had a registered manager in post who had been registered since October 2010. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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. However at the time of our inspection the home was being managed by a temporary manager from another of the provider’s homes due to the registered manager being absent from work.

CQC is required to monitor the operation of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are in place to protect people where they do not have capacity to make decisions and where it is considered necessary to restrict their freedom in some way, usually to protect themselves or others. At the time of the inspection we found that applications had been made to the local authority in relation to people who lived at Ashwood and a number of these were pending an outcome.

At this inspection we found there were insufficient numbers of staff deployed to provide care safely to people living in Ashwood. We found examples where people’s health and wellbeing had suffered as a result of this.

Systems were not in place to monitor, review and investigate incidents and accidents to keep people safe from the risk of harm or abuse.

Risk assessments had not always been developed to positively manage risks to people, once staff had identified a change to a person’s support needs.

People’s medicines were managed and stored safely, and people received their medicines as they were prescribed.

People were supported by staff who had undergone a robust recruitment process to ensure they were of sufficiently good character to provide care to people.

We found that staff had not been supported by the manager or provider to enable them to carry out their role sufficiently.

People’s nutritional needs were not always met or monitored. People were not able to freely choose what they ate and people’s weights and dietary records had not been maintained.

People we spoke with told us they had access to a range of health professionals, and records demonstrated they were referred quickly when their needs changed.

Staff spoke to people in a kind, patient and friendly manner, however people’s appearance meant they were not always treated in a dignified way.

People’s wellbeing was not always supported by staff who provided care and support to them. They did not ensure that they were meeting their individual needs and preferences by ensuring people’s social needs were met.

People did not always receive care that was responsive to their needs.

We found that Ashwood did not promote a culture that promoted support, fairness, transparency and an open culture. Staff morale was low, and at the time of our inspection, little had been done to address this.

People did not receive care that was well led and regularly monitored and reviewed to ensure the care was of sufficient high quality.