Ashley House Residential Home

Ashley House Residential Home (known as Ashley House) is a residential care home providing personal care to 15 people aged 65 and over at the time of the inspection. The service can support up to 18 people. The home has 12 single rooms and 3 shared rooms. People share bathrooms and there is a communal lounge and dining area.

People’s experience of using this service and what we found

Relatives were positive about the care and support provided by Ashley House. They said the communication with the home was good. Staff were also positive about working at the home and thought there were enough staff on duty to meet people’s needs. Staff continued to be safely recruited.

Staff had completed training in safeguarding and knew what types of incidents needed to be reported. A recent safeguarding concern had been reported to the safeguarding team and investigated appropriately. Risk assessments were completed, and guidance provided for staff to manage these risks. These were reviewed each month. The home was clean throughout and current government guidelines were being followed for the use of PPE and for visitors to the home.

People received their medicines as prescribed. We have made a recommendation about the recording of when topical creams are applied. A quality assurance system was in place. The registered manager had been pro-active in asking for two external audits to be completed. Any recommendations made in these audits were being implemented.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 7 January 2020).

Why we inspected

Our monitoring of Ashley House raised concerns in relation to safeguarding. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service has remained good. This is based on the findings at this inspection.

We found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe and well led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Ashley House Residential Home on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

We found the following examples of good practice.

¿ The connecting doors in the lounge had been closed to create two separate lounges. One side was used by people who had tested positive for COVID-19 and the other for those who were negative.

¿ A visiting area had been created by the rear entrance. Family members would not have to go through the rest of the home. A table with a Perspex screen had been set up to reduce the risk when people met their families. This would be used again when local lockdown rules allow.

Further information is in the detailed findings below.

Ashley House is a residential care home providing personal care to 18 people aged 65 and over at the time of the inspection. The service can support up to 18 people.

The home has 12 single rooms and 3 shared rooms. People share bathrooms and there is a communal lounge and dining area.

People’s experience of using this service and what we found

The management structure of the service had been strengthened with the appointment of a deputy manager and senior care workers. This meant a robust quality assurance system was in place. All actions and recommendations from our last inspection had been implemented.

Care plans and risk assessments were in place, providing guidance for staff on how to meet people’s identified needs. People received the support they needed to maintain their health and wellbeing. Medicines were safely managed and administered as prescribed.

People and relatives were very positive about the staff team; stating they were kind, respectful and very caring. A relative said, “It’s restored my faith that there are people and places that genuinely want to care, look after and help you.”

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

There were enough staff to meet people’s needs. Staff were safely recruited. There was an activity programme in place, which included visits from local school children and a group of befrienders. We received mixed feedback about the activities, with some people and relatives saying the staff did not always have time to organise the activities in addition to their caring responsibilities.

Staff felt well supported by the management team and said they had enough training to meet people’s needs.

There had been a marked improvement in the environment at Ashley House. Communal areas and some bedrooms had been re-decorated. More improvements were planned, including the replacement of the corridor and dining room carpets.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection (and update)

The last rating for this service was requires improvement (published 25 December 2018) and there were four breaches of regulations. CQC issued two warning notices and the provider completed an action plan to show what they would do and by when to improve. CQC also met with the provider to follow up on the action we had told the provider to take.

At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Ashley House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

The home is registered to accommodate up to 18 people, with 17 people living at Ashley House at the time of our inspection. There are three shared rooms and 13 single rooms with people sharing bathrooms. The home is an older building with lift access to the first floor. There are two lounges and a dining room on the ground floor and a garden accessible by a ramp to the rear.

Ashley house has a registered manager who had been in post since 2014. 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 last inspection in September 2017 we found breaches in three Regulations because care plans and risk assessments did not include all the details of people’s support needs, activities were not available for people to take part in, there were hazards around the building, medicines were not always managed safely and the quality assurance system was not sufficiently robust.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve all the five key questions of safe, effective, caring, responsive and well led to at least good.

At this inspection we found there had been some improvements made. Medicines were administered as prescribed, although guidance for when to administer medicines not taken regularly had not been written for people who had recently moved to the home. Hazards around the building had been addressed and a programme of refurbishment was in place, with some improvements having been completed in 2018 and more planned into 2019. More activities were being organised.

However, there were continued breaches in two regulations. There was an inconsistent use of pre-admission assessments and care plans for people moving to the home were not completed in a timely manner. Care plans were personalised, included all of people’s support needs and were regularly reviewed. More detail was required in some care plans to provide clear guidance for staff in how to meet people’s needs.

Quality assurance systems were not robust and audits had not been completed regularly. Formal checks of the call bell system, water temperatures, window restrictors and wheelchairs were not made. The providers regularly visited the home but did not make any formal checks to assure themselves of the quality of the service or to identify any improvements that may be required.

A new breach was found as the home was not following the principles of the Mental Capacity Act (2005). People assessed as not having the capacity to consent had signed consent forms for their care and support. Decision specific capacity assessments and best interest decisions were not in place.

There was a further breach as issues identified in a legionella risk assessment had not been acted upon and emergency lighting bulbs had not been replaced in a timely manner.

The registered manager had had little managerial support since March 2018 when the deputy manager had left the service. New senior care workers had recently been appointed and a new deputy manager was due to start work the week after our inspection. This should provide additional support for the registered manager, with some tasks being delegated to the new management team.

Incidents and accidents were recorded and reviewed by the registered manager to look if there were any patterns. We have made a recommendation for best practice guidelines to be followed to evidence the action taken following an incident or accident.

A safe system of recruitment was in place. We have made a recommendation that reasons for any gaps in candidate’s employment history are recorded as per Schedule 3 of the Health and Social Care regulations.

People felt safe living at Ashley House. People and their relatives were complimentary about the staff and the support they received. There were sufficient staff on duty to meet people’s assessed needs. Staff knew people’s needs and their likes and dislikes.

People were supported to maintain their health and nutrition. Medical professionals we spoke with were positive about the home and said they made referrals to them in a timely manner, for example of any concerns about a person’s skin integrity. They said that pressure area care was good at Ashley House.

Staff received the training and support they needed to carry out their roles. Supervision meetings had been held, although not on a regular basis. Staff enjoyed working at the service and said the registered manager was approachable and would listen to any ideas or concerns they had.

The home had received a certificate of commendation from the specialist palliative care team for the support provided as people approached the end of their life.

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Ashley House Residential Home (known as 'Ashley House' by the people who live and work there) is registered to provide accommodation and personal care for up to 18 people, some of whom are living with dementia, there were 17 people living at the home at the time of our inspection. The home is situated on the main road close to local amenities and public transport links into Manchester city centre, Didsbury and Chorlton. The home is a large detached property set in its own grounds. Car parking is available on the road. There is a lounge and a separate dining room on the ground floor. There is a passenger lift in place along with facilities for cooking, dining, personal care, relaxing and leisure.

During this inspection we found six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, relating to management of medicines, risk assessments, person centred care, meeting people's social needs and quality assurance. You can see what action we told the registered provider to take at the back of the full version of the report.

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 found people were not always protected from risks associated with their care because risk assessments were not always robust enough to provide guidance and direction to staff about how to keep people safe. People did not always have sufficient detail in their care plans to provide guidance and direction to staff about how to meet their needs.

People's medicines were not managed safely. For example, we observed one care worker not safely observing the person taking their medicines they had just administered. We found the storage of controlled drugs did not meet the requirements of the Misuse of Drugs Act 1971. We found there were no plans, or 'when required' (PRN) protocols in place to inform staff when and how they should administer people medicines that were not required routinely.

During our tour of the building we noted several potential safety hazards. We found in the first floor bathroom had two radiator covers stored behind the bath tub. Both radiator covers had sharp edges and we requested that they were removed immediately. We found items of clothing and an inflatable mattress were being stored under the stairwell, this posed as a potential fire risk.

Overall people and relatives spoken with were positive and complimentary about the service they received at the home. People told us that they felt safe and were cared for.

During this inspection we found there were enough staff available to meet the needs of people living at the home. However, staff didn’t have time to provide social interaction with people and we noted the care hours during the weekend were reduced by one 8am to 2pm shift. We have made a recommendation the home considers introducing a dependency tool which will provide further clarification on whether the current staffing levels are adequate.

Activities on offer to people were limited. We received a negative response from people in relation to activities. The range of activities available was not always appropriate or stimulating for people. This meant people were not always protected from social isolation.

We saw caring interactions between staff and people. However, we observed one care worker not engaging with a person in a caring and sensitive manner which meant the person’s dignity was not respected.

The home was generally clean and tidy, although we found a malodour in communal areas. The registered manager suggested the carpets were planned to be replaced, but no clear timescale of this work had been agreed.

Staff had received appropriate training, supervision, and appraisals to support them in their roles. Staff, with the support of the management team identified their professional needs and development and took action to achieve them. However, we have made a recommendation because it was not clear how new staff were supported through the care certificate. This meant we could not be fully assured new staff had received a robust induction in health and social care.

We noted the home had two fire risk assessments in place dated December 2016 and September 2014 which had been completed by two external fire safety companies. The registered manager informed us the fire risk assessment in December 2016 was deemed not to be sufficient by Manchester Fire and Rescue Service in March 2017, and they suggested the home uses the fire risk assessment from March 2014. We noted there was no clear documentation stating this. We have made a recommendation the provider undertakes a new fire risk assessment ensuring this replaces the any outstanding fire risk assessments to avoid confusion.

We found the service was working within the principles of the Mental Capacity Act (2005) (MCA). Best interest meetings and capacity assessments were held where required. Applications for Deprivation of Liberty Safeguards (DoLS) were appropriately made. However, we found staff understanding of the MCA 2005 and DoLS was limited as no training had been provided. We noted some consent forms had not been completed correctly.

A process was in place for managing complaints and the home's complaints procedure was displayed so that people had access to this information. People and relatives told us they would raise any concerns with the manager.

Audits on the home's quality were not accurate which meant systems to improve the quality of provision at the home were not always effective. We found the home in breach of the regulation in relation to good governance as there were not effective systems in place to monitor the quality of the service.

An inspector visited this service on 9 September to carry out an inspection. Prior to our visit we looked at all the information we hold on this service to help us to plan and focus on our five questions;

Is the service caring?

Is the service responsive?

Is the service safe?

Is the service effective?

Is the service well led?

During this inspection we spoke with one relative, three care staff and the manager of Ashley House. We also spoke with four people who lived at the home. Below is a summary of what we found.

Is the service caring?

The people we spoke with were happy with the care and support provided by Ashley House. Comments included; "I've no complaints about anything', 'I like it here' and 'I wouldn't want to go anywhere else.' Our observations showed people were spoken with politely and with respect.

Is the service responsive?

We saw people were encouraged to give feedback on the service in the form of surveys, and meetings took place to enable people to make comments and suggestions. We saw some audits had been put into place and some systems were still required to be introduced to identify and manage risks relating to the health, welfare and safety of people who used the service. We concluded improvements were required.

Is the service safe?

We saw some systems were in place to ensure people were safe. We saw there was a safeguarding policy in place which contained contact numbers for appropriate authorities and this was accessible to staff. We spoke with three staff who were able to describe the action they would take if they were concerned that people at Ashley House were at risk of harm or abuse.

We noted the environment required improvement to enable people to live safely. For example we saw areas of the home required repair and cleaning.

We found records required further information to enable staff to deliver safe and effective care.

We also checked if sufficient numbers of suitably skilled staff were available to meet people's needs. On the day of the inspection we saw staff supported people promptly and the people we spoke with told us they were happy with the staffing provision at the home.

The CQC monitors the operation in care homes of the Deprivation of Liberty Safeguards (DoLS). At Ashley House there were no people for whom a DoLS authorisation had been agreed at the time of our visit and the manager told us they regularly reviewed people who used the service to ensure the appropriate processes were followed.

Is the service effective?

We saw people had access to a varied diet to enable them to meet their nutritional needs. We observed staff encouraging people to eat and drink and choice was available if people did not want the meal provided. We saw people were referred to other health professionals as required.

Is the service well led?

The service had a manager in place who has been registered with the Care Quality Commission since March 2014.

We looked at a sample of audits and saw there were some systems in place to identify when improvements were required. However we noted the audit system had not identified shortfalls in records or required maintenance to the environment.

We were informed by the manager a safeguarding incident had been referred to the local authority. The manager told us they had not referred this to the Care Quality Commission. We considered improvements were required to ensure safeguarding incidents were monitored and reviewed to identify and manage any identified risks. We considered improvements were required to ensure the service was well led.

We spoke with one relative who told us they found the manager approachable and they would speak with them if they had any concerns.

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.

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

Is the service safe?

Staff records contained all the information required by the Health and Social Care Act. This meant the provider could demonstrate that staff employed to work at the home were suitable and had the skills and experience needed to safely support the people accommodated.

We spoke with people who lived at the home who told us they felt safe and secure. We spoke with visitors who told us: 'When I leave here I know (my relative) is in safe hands and they (staff) look after her very well.'

The staff we spoke with demonstrated an awareness of local safeguarding policies and procedures and understood the referral process. Staff were able to tell us what they would do if they had any concerns about people's safety.

People's needs were assessed before they moved in to the home. This was to make sure the staff were able to meet their care needs. Care plans were in place and included risk assessments.

We saw some risk assessments were not fully reflected in care plans and this posed a potential risk that people might not receive appropriate care and treatment.

The registered manager who was new in post; recognised the need to review and update people's care plans so they provided

staff with accurate, detailed and up to date information.

There was a staffing rota to ensure adequate support was provided to people who lived at the home. The registered manager took individual care needs into account when making decisions about the numbers, qualifications, skills and experience required for carers.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Suitable policies and procedures were in place and staff had been trained to understand their responsibilities under the DoLS Codes of Practice. No applications had been made to deprive people living in the home of their liberty. Care plans and our observation of staff provided evidence of good practice in applying the least restrictive options to promote each person's autonomy.

Is the service effective?

An assessment of need was carried out before people moved into the home. This was to make sure it was the most appropriate place to meet their care needs. Care plans were being reviewed but there was no evidence that people or their relatives had been involved in the review process.

Dietary needs had been identified but they were not always reflected in the care plans. We did not see any nutritional assessments or any evidence that specialist advice had been sought for people who had special dietary needs.

The registered manager recognised the need to involve people in developing and reviewing care plans. We saw relatives had been sent a questionnaire to update contact details.

The registered manager arranged a 'Meet and Greet' meeting to get to know the relatives of people who lived at the home. Information leaflets about advocacy services were displayed on the notice board in the hallway.

There was a complaints procedure in place. People knew how to make a complaint if they were unhappy. The people we spoke with told us they had never had cause to complain but would discuss their concerns with the manager. People felt sure any concerns or complaints would be investigated and appropriate action taken.

Is the service caring?

We spoke with visitors who told us they were very happy with the care their relative received. Comments included: 'They (staff) are definitely very caring; they look after my relative very well.' 'They (staff) know what they are doing.'

We spoke with people who lived at the home who told us: 'It's a nice place I like it here they are all wonderful.' 'There are new owners so we will see.' 'They are all nice; we get the best of everything.' 'It has changed recently.' 'There is not much going on.' 'They treat me very well.' 'I am quite contented I can do what I want and if I need help they are here for me.'

We spent time observing interactions between the staff and people who lived at the home. We saw care was provided to a high standard. We saw staff approached people with respect in a way that maintained people's dignity.

We have asked the provider to tell us how they are going to monitor the quality of the service they provide.

Is the service responsive?

The provider worked with other agencies such as community health and social care professionals. People were supported to attend hospital appointments and each person had access to a general practitioner.

People told us they would speak to the manager if they had any concerns and felt sure their concerns would be listened to and appropriate action taken.

The registered manager recognised the need for an effective quality monitoring system and was researching the most appropriate system for the home.

Is the service well-led?

The registered manager had not had sufficient time to carry out a full audit of the systems in place at the home.

We saw a review of care plans was underway. The registered manager told us they were planning to introduce a new format for care plans.

We spoke with staff who told us the manager had been supportive and had arranged various training courses and meetings. The staff we spoke with told us they felt the manager listened to their views and opinions.

We spoke with visitors who told us they had seen some improvements over the period of time the manager had been in post.