Ashleigh House

Ashleigh House is a care home providing personal care to up to 30 people. The home provides support to younger adults who may live with dementia or mental health issues. At the time of our inspection there were 20 people living at the home.

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

We carried out this inspection in response to concerns that had been raised with us regarding the cleanliness of the building. We shared these concerns with the local authority lead infection control nurse who visited Ashleigh House on 11 October 2023. Significant concerns were found regarding cleanliness of the home and equipment used for medicine administration. The provider responded to these concerns promptly with deep cleans, staff training and additional housekeeping staff.

Care records were not always completed or accurate. Some care plans, risk assessments and best interest decisions had not always been completed with specific details required about people’s care. Audits did not always identify the recording issues we found.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. We found not all capacity assessments and best interest records had been completed when required and people subject to Deprivation of Liberty Safeguards (DoLS) were able to leave the building freely.

Accidents and incidents and safeguarding notifications had not always been consistently recorded and reported. Medicines were not always managed safely. Some records regarding as and when required medicines needed updating and administration practice we observed was poor. A recent provider audit had found the concerns we had relating to medicine records and there was an action plan in place to address this.

There were no planned activities taking place and people said there was nothing much to do. People's care plans did not reflect clear goals and outcomes to support their independent living skills.

We observed that staff did not always uphold people's dignity and that professional boundaries might not always be maintained. We have made a recommendation about this about.

The acting manager, senior management team and staff were open and honest with us during the inspection. Staff said the last 6 months at the service had been "chaotic" and "a bad whirlwind" as several managers had come into the service then left. Staff told us they felt supported by the acting manager who had only been in post since August 2023. Staff told us they were keen to learn and drive improvement to ensure people received the best possible care.

Staffing levels were sufficient to meet people’s needs and staff were recruited safely.

People were offered choices at mealtimes and told us they enjoyed the food provided in the home. The home ensured people had access to health care professionals when required.

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 29 June 2021).

Why we inspected

The inspection was prompted in part due to concerns received about areas of concern such as infection control and staffing. A decision was made for us to inspect and examine those risks.

Enforcement

We have identified breaches in relation to person-centred care, safe care and treatment and governance of the service.

Please see what action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Ashleigh House is a residential care home that is registered to provide accommodation for up to 30 people. It provides care to people living with mental health problems. At the time of the inspection 18 people who used the service.

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

The registered manager and staff had worked hard to improve the assessment of people’s needs but the provider’s template focused on a person’s physical rather than their mental health. They had recognised this shortfall in their assessment tools and a new electronic care record system was being developed, which was bespoke to the service. The registered manager immediately added templates to assist staff working with people who were subject to sections under the Mental Health Act 1983 (amended 2007).

Staff had completed mandatory training, supervision and appraisals. The staff had received training around working with people who lived with mental health needs. Further in-depth training in mental health was planned but staff continued to lack knowledge around the Mental Health Act 1983 (amended 2007), the code of practice and forensic histories. This impacted on how staff planned people’s care and identified risks. The registered manager immediately sought training in these areas.

Since the last inspection the provider and registered manager had made improvements to the service. They had strengthened the governance arrangement and improved the audits. These changes had assisted the registered manager to identify any gaps in practice and put plans in place to resolve them.

The bathrooms, toilet, windows, facades had been refurbished and the fire alarm system changed. Action had been taken to ensure the home complied with fire authority requirements. Decorative work had been completed throughout the home.

Care staff adhered to Covid-19 guidance on working in a care setting. There was enough personal protective equipment (PPE) such as aprons, gloves and masks. Staff had undertaken training in putting on and taking off PPE. Visitors were screened before entering the building.

There were enough staff on duty. The provider reviewed the purpose of the service and employed additional staff who supported people with the rehabilitative work. They reviewed the needs of people and worked with commissioners to ensure people were allocated one-to-one hours when needed.

People felt the home was safe. They commented on how staff were kind and compassionate.

Incident monitoring records were used, and each event was thoroughly reviewed with lessons to be learnt and put into action. Medicine management was effective.

Staff had received additional training on the application of the Mental Capacity Act 2005 and understood how to apply this legislation. None of the people who used the service lacked capacity. Where people made unwise decisions, staff worked with them and the multidisciplinary team to develop strategies to manage the risks associated with their decisions.

The new cook provided healthy and nutritious meals for people throughout the week. Nutritional assessment tools were in place and staff encouraged people to eat a balanced diet. Staff took appropriate action if people experienced weight loss.

The feedback we received was very complimentary about the registered manager. People felt the registered manager had made improvements. They were confident the improvements would continue to be made.

Staff told us the registered manager and deputy manager were approachable and closely listened to their views. They felt positive about how the service was being operated. The registered manager and deputy manager had formed excellent working relationships with local care co-ordinators and health professionals. This had greatly improved people’s access to appropriate services and support.

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 requires improvement (published 17 July 2019).

Why we inspected

We carried out an unannounced inspection of this service in July 2019. Breaches of legal requirements were found. The provider completed an action plan after the inspection to show what they would do and by when to improve safe care and treatment, need for consent and staffing.

We undertook this focused inspection to check the provider had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions safe, effective and well-led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from requires improvement to good. This is based on the findings 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 coronavirus and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Ashleigh House 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.

People’s experience of using this service: During our inspection we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 relating to ensuring the safe care of people, need for consent principles were followed and staff were trained.

The provider had not fully completed matters raised at the last inspection. Half of the bathrooms and toilets remained out of commission, windows needed replacing and the façade at the back of the home had not been renewed. They had not met all the fire authority requirements, which were outlined in a letter dated 25 January 2019. Plans were in place to deal with these matters and work had commenced to refurbish the bathrooms.

Since the last inspection the occupancy had significantly increased but at the time of the inspection care staff hours had remained the same. A deputy manager, cook covering weekdays and activity coordinator had been employed but the provider could not show us how they ensured there were enough staff to deliver rehabilitative work, personal care, safely manage situations where people were distressed and cook the meals on a weekend. Two staff on duty overnight, which was insufficient to ensure people’s safety could be maintained.

Staff were completing mandatory training, supervision and appraisals. The staff lack of training around working with people who live with mental health needs was significantly impacting how staff responded to people, planned their care, identify risks, assessed individual's needs and worked in line with best practice.

Staff were not following principles round obtaining consent and care records suggested they imposed restrictions on people even when they deemed them to have capacity. The registered manager and staff had worked hard to improve the assessment of people’s needs but the lack of training meant they were not accurate.

Nutritional assessment tools were in place and staff encouraged people to eat a balanced diet. However, when people lost weight or had a low body mass index (BMI) staff did not always act in timely manner to refer them to the GP and dieticians. Staff did the cooking at the weekend and it was not clear why. Staff had not received the food hygiene training.

The provider had a system in place for overseeing the service and had identified gaps in practice plus put action plans in place. However, the timescales they gave for completing action was unrealistic and lead to areas that needed urgent attention being left for months and in some cases years before being addressed. The regional manager and registered manager were clearly aware of gaps and had acted to make improvements where they could.

People spoke extremely positively about the staff at the service, describing them as kind and caring. One person told us the staff had restored their faith in mental health services. Staff treated people with dignity and respect. Staff were extremely empathetic and non-judgemental when working with people.

Staff told us that the registered manager and deputy were approachable and closely listened to their views. They felt positive about how the service was being operated. Incident monitoring records were used, and each event was thoroughly reviewed with lessons to be learnt and put into action. People felt that this registered manager would listen and act on complaints. Medicine management was effective.

Staff tried to be proactive and support people to enjoy a range of activities. Staff had supported some people to gain paid employment.

The registered manager and deputy manager had formed excellent working relationships with local care co-ordinators and this had led to them having the confidence to place more people at the service.

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

Rating at last inspection: Requires improvement (report published 18 May 2018) and there were two breaches of regulation. We had found breaches relating to governance and staff had the necessary tools to ensure action was taken when people lacked the capacity to consent. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations relating to governance.

The service remains rated requires improvement and this is the second time it has received this rating.

Why we inspected: This was a planned inspection based on the rating at the last inspection.

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

We last inspected this service in 28 September 2015, and found the service was complying with all the regulations and we rated the service as ‘Good.’

In November 2017 owners of Salutem Healthcare replaced the directors of Pathways Care Group Limited and took over the operation of the service. This change of leadership also meant that the provider has become a part of a wider Salutem Healthcare consortium. Pathways Care Group Limited remains listed, as an active legal entity on Company House and thus remains appropriately registered with CQC. However, some of their documentation contains information about this new company, as does the website.

During this inspection we found the service needed to take action to ensure they met all the fundamental standards we inspected against.

Ashleigh House is a ‘care home’. People in care homes receive accommodation and 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. Ashleigh House is registered to provide care and accommodation for up to 30 people who are living with dementia or a mental health condition. On the day of our inspection there were 15 people using the service.

Whilst reviewing the information for the service we found that since the last inspection the provider’s website had changed and stated that Ashleigh House provided 20 places for people living with dementia and people with a mental health condition in to two 10 place units. However, we found this was not the case as 27 places were available for people with mental health needs. The provider rectified the website immediately.

The registered manager told us that the service was being redesigned and would offer services for people living with mental health conditions who needed 24 hour support and then progressive step-down and transition services, which were aimed at supporting people to move to their own accommodation. The regional manager also discussed future plans for the service such as employing a clinical nurse lead and opening a day unit that provided drop-in services, a meal on a Sunday, access to welfare and citizens advice for local people living with mental health needs. The intention they told us was to offer wider services so that outreach and supported living provision could also be offered from Ashleigh House.

We discussed with the regional manager and registered manager the need to submit an application to vary their conditions of registration so the number of available places could be reduced to 27. As some of the people at the service were also living with a learning disability that this needed to be added their service user bands. They undertook to do this immediately.

The service had a manager who became the registered manager in September 2015. 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.

On the first day of the inspection we found that the lift had been out of order for a year. Also the local NHS Trust’s infection control team had visited the previous year and required a number of changes to the environment to be made immediately, which included replacing flooring. We found that although some of the damaged flooring had been replaced other areas such as stairs needed immediate attention. The outside of the building was tired and some areas of the façade were cracked. When we returned on 6 April 2018 action had been taken to repair the lift and replace the badly damaged flooring on the stairs. The registered manager also provided evidence to confirm that work had commenced to repair the cladding and exterior facilities, bathrooms and flooring. The regional manager discussed the provider's intention to complete a full refurbishment of the service over the next year and how the finances for this work had been agreed.

We found that upstairs the service had been divided into three units and staff used a key to access two units. One unit could only be accessed one-way. We queried the impact this change had on the management of the service and fire safety. The registered manager immediately fitted a means to leave the unit both ways. They confirmed on 29 March 2018 that fire safety measures were robust and in the event of a fire all of the doors automatically released. Therefore two fire exit routes were available per unit, which meant that people would be able to evacuate safely in the event of a fire.

We found that although staff had previously received training in working with people who lived with mental health conditions they needed further training in this specialism, for instance completing risk management with people who have an offending history and understanding the use of the Mental Health Act 1983 (amended 2007) in the community. We noted that training around working with people who had mental health conditions did not form part of the provider’s mandatory training.

The care records contained no information about people’s capacity and no Mental Capacity Act (MCA) assessments or ‘best interests’ decisions had been completed. However, we found a DoLS authorisation had been requested and some people had appointees for their finances, which suggested some individual's lacked the capacity to make decisions.

We found that staff needed to be more proactive and find out if people were subject to any court restrictions, conditional discharges from sections of the Mental Health Act 1983 (amended 2007) or Community Treatment Order conditions.

Staff knew the people they were supporting but the initial care records we reviewed did not reflect this knowledge. The care records were very difficult to navigate and had not been updated for several years. They did not support staff to fully understand people’s histories, the impact of their mental health needs on their behaviour, be able to contextualise and formulate risk profiles for people or determine what restrictions were in place. When we returned to the service we found that the registered manager had adopted care record templates from a sister service and had updated care records. We found the completed care records were far more informative and addressed risks that may be posed. The regional manager also discussed how the provider was in the process of designing bespoke care records for service.

Although the domestic staff tried their best to keep the service clean, we found many areas of the service were in need of cleaning. Also we found that staff had not been trained around best practice when completing cleaning tasks. The registered manager immediately ensured a deep clean was completed and told us that staff had been enrolled on diploma's in working in this field.

On the first day of the visit we found two staff were on duty during the day and night. Additional staff members were being employed to work during the day and were in post when we returned to the service. The regional manager discussed the plan that was in place to ensure there were sufficient staff in place to support all of the people and offer re-ablement programmes.

The registered manager also explained they intended to admit a person who may have mobility difficulties. We found the current facilities would not support people who had mobility impairments and no consideration had been given to installing aides or that the lift would be located on the unit for people who were independent. The registered manager immediately ensured the environment was assessed and purchased equipment that would support people who had mobility needs. We found on our return that an occupational therapist had assessed the person and equipment was in place.

We found that the provider was in the process of introducing new systems for assessing and monitoring the performance of the service but those that had been in place were not effective. The registered manager had been completing audits but these had not picked up issues we highlighted, for instance the broken lift and uninformative care records.

Safeguarding and whistleblowing procedures were in place. Staff we spoke with understood what actions they would need to take if concerns arose. however, we noted that although staff understood what to do when people raised complaints they did not always record this in the complaint's log. We discussed this with the registered manager who took immediate action to ensure all concerns and the action they had taken was recorded.

People were on the whole complimentary about the staff at the service and their attitude. They told us the service was met their needs. People told us that staff were kind and caring.

We found the systems for the management of medicines ensured people received their medicines safely.

People were supported to maintain a healthy diet and to access external professionals to monitor and promote their health.

Effective recruitment and selection procedures were in place and we saw that appropriate checks had been undertaken before staff began work.

We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, which related to safe care and treatment; the need for consent; staffing; and having good governance systems in place.

You can see what action we told the registered provider to take at the back of the full version of the report.

This was a responsive inspection due to concerns raised and we looked to see if the service was safe and well led.

The summary is based on our observations during the inspection, speaking with people using the service, and the staff supporting them and from looking at records.

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

Is the service safe?

We looked through three care files out of a possible 14. This was due to concerning information stating that note keeping was poor and new staff were not able to follow care plans which put people at risk. We found the care files provided enough information to make sure people were supported in the way they wanted. Staff employed by Ashleigh House had the right qualifications, skills and experience.

We asked to see the services policy on behaviour that challenges, due to people who used the service having early onset dementia and mental health conditions. Ashleigh House did not have a policy for behaviour that challenges, they did have a policy on aggression towards staff but this did not cover the support for someone showing behaviour that challenges which is not always aggression.

Is the service well-led?

Minutes from staff meetings were available for us to see. Due to a number of issues within the home, staff meetings had not taken place as regularly this year. This was something the manager was aware of and told us they were going to rectify.

In the last 18 months, 26 staff had left the service's employment. Four of these staff had left due to their own choice, 22 staff had been released following unsuccessful probation periods or dismissed due to misconduct. The manager told us that removing some staff from the home had a positive impact on the remaining staff. New staff had been recruited correctly but there were gaps in staff training.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care home. The home had proper policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards. At the time of our inspection they had one DoLs safeguarding authorisation in place.

What people told us:

We spoke with four people who used the service, one relative, the manager and three members of staff. People who used the service said 'I really like it here, I can do what I want,' and 'I can get a cup of tea or something to eat whenever I want,' and 'All the staff are fine.' Another person said 'You get plenty of choice and can go where you want, I prefer to eat downstairs and I do.'

The relative we spoke with said 'It's always welcoming with a nice and friendly atmosphere,' and 'I can come whenever I want, they have nice safe, friendly staff.'

Staff we spoke with said 'I have not been here long, but I really enjoy it,' and 'It's a lovely place to work, all the staff and clients are lovely.' and 'People who live here like to do their own thing but I try to think of things we can do together like movie quizzes.'

Below is a summary of what we found. The summary was based on our observations during the inspection, we spoke with people who used the service and staff who worked there, and looked at records.

Is the service caring? ' People told us they were given choices about how their care was provided and that these were respected by the service. We spoke with three people who used the service who were complimentary about the staff at the service and stated they could raise any issue and staff were very quick to respond.

Is the service responsive? ' The service held regular meetings with people who lived at Ashleigh House and people were asked about their views on the quality of the service. The service had good relationships with other health and social care professionals and we saw that the service was quick to request support for people's physical and mental health if it was required.

Is the service safe? ' The service had safeguarding policies and procedures in place and the manager and staff we spoke with knew how to respond to any concerns that were raised with them. Three people we spoke with all said they felt safe at the service. One person said; 'I feel safe here, I talk to the staff if I feel low or lonely'. There were good systems in place for ensuring medication was stored, administered and disposed of safely. One staff told us; 'It's a lot easier now we have a new system in place, I feel much more confident with it'.

Is the service effective? ' We saw that care plans had a person centred format, and they showed how people's views and preferences about their care had been recorded. People were supported to give their consent so information the service held about people was used appropriately with staff and other professionals on a need to know basis.

Is the service well-led? ' The manager had a system of seeking views from people who used the service and held meetings with the staff team and provided training and support through regular supervisions. The manager also reviewed incident reports at least weekly and checked the quality of recording in peoples care plans.

What people told us '

We spoke with four people who ilved at Ashleigh House and observed staff and the manager have lots of positive and supportive conversations with people throughout the day.

Comments from people included; 'I love it, I'm happy living here';

'It's sound here';

'The staff have got our interests at heart';

The staff are nice';

'I do feel safe here, I can tell the staff if I've got a problem';

'We can make our own breakfast, lunch and supper, it's great';

'There is plenty to do it's just whether I can be bothered to get off my butt and do it!'.

Another person said they had help from staff and 'We do things like bingo, pool competitions and have trips bowling. The staff and the manager are alright'.

We saw that staff were supported to carry out their roles and there were enough qualified, skilled and experienced staff to meet people's needs. The provider followed the correct procedures regarding the risk of infection. The provider had systems in place to monitor the quality of service provided.

Records were held securely and people had signed to show they were involved in their care plans and risk assessments. One person told us; 'I love it here it's a home from home'.

Staff members had a good knowledge of infection control procedures. We saw the environment whilst still being homely, had equipment available such as personal protective equipment and colour coded mops to reduce the risks from poor infection control, however we discussed with the registered manager that the laundry equipment was not adequate to address infection control regulations.

We found that provider had accurate records in place to ensure that people were protected form the risks of unsafe or inappropriate care.

The other person we spoke with said they were 'As happy as they could be. There were no major things wrong.' They felt that the staff looked after their needs and if they needed anything they would get it for them. They knew they had a care plan but were not involved in it through their choice. They also told us that they were going on an outing to the cinema that afternoon.

We previously visited Ashleigh House on the 27 September 2012. During this visits we found that care and treatment was not planned and delivered in a way that ensured people's safety and welfare.

At this visit we found that a review of all care plans had been initiated and the manager told us that of the eleven care plans five were to satisfaction. We examined six care plans and found that three were not fit for purpose. One person's care plan had no risk assessments to address risks identified and reviews and updates had not been carried out. In the case of the other two people care plans and risk assessments had not been updated or reviewed.

One person said that 'it would be better if we had a proper covered area to smoke outside'. Another said 'things have changed for the better in the last few weeks, I feel happier and safer'. We were also told by a visiting social worker; 'the atmosphere today compared to a few weeks ago, is totally different. Staff are smiling again and I can see a real change.'

We spoke to a visiting social worker who told us 'I had no concerns until a few weeks ago. My client had previously had excellent support from staff'.

People told us about activities that they did such as dominoes, painting and cooking. We also saw activities which were due to take place which included a nature walk and a DVD night. Both staff and service users told us that activities were just beginning to be organised properly but needed better co-ordination.

People told us that staff were starting to encourage service users to be more independent for example prompting them to cook their own food and to tidy up their crockery and cutlery after they had eaten a meal or snack. One person said that they 'didn't have a bad word to say about any of the staff' and they felt they kept them safe.