This comprehensive inspection took place on 30 April 2018 and the 8 and 14 May 2018. This inspection was brought forward because we received concerns about the service. These related to staff levels, safeguarding concerns and staff not following the Mental Capacity Act 2005 (MCA).

Ashdowne Care Centre 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.

Ashdowne Care Centre is registered to provide accommodation with nursing or personal care, for up to 60 people. There were 45 people using the service on the first day of our inspection. The service is located in the town of Tiverton. It comprises of two detached, two storey buildings linked by a corridor. The home is divided into two units, one in each building, Ashdowne and Pinnexmoor. The Ashdowne unit is primarily used for people with physical disability and the Pinnexmoor unit is for people with dementia or a mental health need. Each of these units has its own staff team, communal spaces and secure outside garden for people to use as they choose.

At our last comprehensive inspection in April 2016 the service was rated good overall and in all domains except effective. We issued the provider with a requirement because they had not ensured people were supported by staff who had the appropriate training and supervision necessary to enable them to carry out the duties they are employed to perform. Following the inspection the provider sent us an action plan telling us the improvements they would make. We returned and undertook a focused inspection in May 2017 and checked to see whether the requirement had been met and found it had been addressed.

A new registered manager started working at the service in May 2017 and registered with CQC In February 2018. A registered manager is a person who has registered with CQC to manage the service. Like registered persons, 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 always protected from risk because people did not always have access to a call bell when in communal areas. People were not protected because risks for each person were not always assessed. Care records contained risk assessments for falls, nutrition monitoring and skin integrity. However these were not always completed in a timely way when people arrived at the service.

There were adequate numbers of staff on duty on the Pinnexmoor unit although concerns were raised regarding the staff levels on the Ashdowne unit. The registered manager explained that there had been staff shortages but staff had undertaken additional duties and staff had come across from the Pinnexmoor unit and the provider’s other service to fill gaps. However they said they had not always been able to cover short notice staff sickness. They had recruited new care staff who were undertaking their induction. This meant that there were staff working on the Ashdowne unit who were learning about the service and developing their experience. They had also increased the staff level because they had two new admissions.

Staff were knowledgeable about recognising the signs of abuse and had a good understanding of how to keep people safe. The registered manager had been working with the local authority safeguarding team regarding safeguarding concerns. During the inspection a person raised a safeguarding concern with CQC. We discussed this with the registered manager and operations manager and they made an alert and took appropriate action.

Recruitment procedures were thorough and all necessary checks were made before new staff commenced employment. New staff had received an induction when they started working at the service. There was a system to ens

This focused inspection took place on 30 March 2017 and was unannounced.

This inspection was to follow up if the required improvements had been made following our last inspection in April 2016. At that visit, we gave the service an overall rating of ‘Good’. However we rated the ‘effective’ domain as requires improvement because we found a breach of regulations. This was because the provider had not ensured people were supported by staff who had the appropriate training and supervision necessary. This meant they may not be able to carry out the duties they were employed to perform. We undertook this focused inspection to check that they had followed their action plan and to confirm that they now met legal requirements. At this inspection we found improvements had been made. All staff were receiving the provider’s mandatory training and support through supervisions and appraisals.

This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for (Ashdowne care Centre) on our website at www.cqc.org.uk”

Ashdowne Care Centre is registered to provide accommodation with nursing or personal care, for up to 60 people. The service is intended for older people, who may have a dementia or mental health need. The home is divided into two units, Ashdowne and Pinnexmoor. Each of these units has its own staff team. The two units are joined by a linked corridor. There were 50 people living at the home at the time of our visit.

The service had two registered managers, who shared the role and responsibilities. As part of their role they also scheduled to undertake nursing duties. 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.

There were systems in place to ensure staff received regular supervisions and an annual appraisal. Staff received the provider’s mandatory training and updates when required. Therefore staff had received appropriate training to meet people’s needs.

Health and social care professionals were regularly involved in people’s care to ensure they received the care and treatment which was right for them.

People were protected by the practice in place in relation to decision making. The registered managers and staff had an understanding of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). DoLS applications had been appropriately made when needed.

People were supported to eat and drink enough and maintain a balanced diet. People were offered a variety of meals and snacks to ensure good health. People’s weight was monitored and where concerns were identified additional snacks and higher calorie foods were offered. People were positive about the food at the service.

This inspection took place on 20 and 21 April 2016 and was unannounced. Ashdowne Care Centre is registered to provide accommodation with nursing or personal care, for up to 60 people. The service is intended for older people, who may have a dementia or mental health need. The home is divided into two units, Ashdowne and Pinnexmoor. Each of these units has its own staff team. The two units are joined by a linked corridor. There were 48 people living at the home at the time of our visit.

We last visited the service in August 2015 to undertake a focused inspection. This visit was to look at actions taken by the provider to address concerns found at a comprehensive inspection in March 2015. There had been significant improvements to the overall management of the home. All legal requirements had been met.

The service had two registered managers in post who shared the role. The second registered manager had moved from another of the provider’s locations in February 2016. A registered manager is a person who has registered with 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.

There were adequate staffing levels to meet people’s needs. Staff had clear leadership roles at the home with delegated responsibilities.

People were supported by staff who had the required recruitment checks in place. Staff had received an induction and were knowledgeable about the signs of abuse and how to report concerns.

The provider had not ensured all staff had undertaken mandatory training to ensure they had the required knowledge to meet people’s needs. Not all staff had received support with their practice through supervisions and appraisals.

People were involved in making day to day decisions. Staff delivered care that was kind and compassionate. People felt they were treated with dignity and respect.

Measures to manage risk were as least restrictive as possible to protect people’s freedom. Medicines were safely managed on people’s behalf.

Care plans were personalised and recognised people’s health, social and psychological needs. Health and social care professionals were regularly involved in people’s care to ensure they received the care and treatment which was right for them.

Staff demonstrated an understanding of their responsibilities in relation to the Mental Capacity Act (MCA) 2005. Where people lacked capacity, mental capacity assessments had been completed and best interest decisions made in line with the MCA.

People were supported to eat and drink enough and maintain a balanced diet. People were positive about the food at the service.

The premises were well managed to keep people safe. A designated maintenance person was employed to undertake repairs and undertake regular checks of the service. There were emergency plans in place to protect people in the event of a fire or emergency.

The provider had a range of quality monitoring systems in place which were used to continually review and improve the service. People were happy they could raise a concern if they needed to and action would be taken.

The provider actively sought the views of people, their relatives and staff through staff and residents meetings and questionnaires to continuously improve the service.

We found a breach of the regulations at this inspection. You can see what action we told the provider to take at the back of the full version of the report.

We carried out an unannounced comprehensive inspection of this service on 26 February and 6 March 2015. During that inspection, four breaches of legal requirements were found. This was because people’s rights were not being protected because appropriate assessments of mental capacity were not being undertaken. People were not receiving the care and treatment appropriate to their needs and were not being able to participate in making decisions regarding their care or treatment. Staff had not received appropriate support and training. The provider did not have systems in place to ensure the safe management of the service. They had not ensured records were promptly accessible and people’s care records did not accurately reflect the care people received.

After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breach. We undertook a focused inspection on the 7 August 2015 to check that they had followed their action plan and to confirm that they now met legal requirements.

This report only covers our findings in relation to this topic. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Ashdowne Care Centre’ on our website at www.cqc.org.uk’

Ashdowne Care Centre is registered to provide accommodation with nursing or personal care, for up to 60 people. The service is intended for older people, who may have needs due to dementia or other mental health needs. The home is divided into two units, Ashdowne and Pinnexmoor, with each area having its own staff team. The two units are joined by a link corridor. There were 49 people living at the home at the time of our inspection.

The service had 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 and associated Regulations about how the service is run.

At our focused inspection on the 7 August 2015, we found that the provider had followed their action plan which they had told us would be completed by the 30 June 2015. There had been significant improvements to the overall management of the home. All legal requirements had been met. There were still areas that needed to improve further. However the provider and the registered manager had plans in place to address these.

Staff were ensuring care and treatment was appropriate to meet people’s needs. Assessments and reviews of people’s care needs were being undertaken and care plans reflected those needs. The staff were ensuring people were able to participate in making decisions regarding their care or treatment. People were being given the opportunity to use the communal areas rather than stay in their rooms. Plans were in place for people’s individual reviews with families where appropriate for September 2015. The district nurse team confirmed they had a good working relationship with the service. They were receiving referrals from the service promptly and appropriately and their advice was being followed.

Staff were acting in accordance with the Mental Capacity Act (MCA) 2005. People rights were being protected by appropriate assessments of capacity being undertaken. Staff were gaining appropriate consent to provide people’s care and treatment and best interest decisions were being made in accordance with the MCA.

The provider was seeking feedback from people who used the service and staff to continually evaluate and improve the service. They had undertaken surveys and residents meetings, feedback had been collated and actions taken in response. .

There were improved quality assurance systems in place to monitor, identify and manage the quality of the service. However, these processes needed to be embedded and sustained to help ensure people experienced a consistently high standard of care. A programme of auditing was in place which the registered manager had undertaken and actions had been put in place to address any concerns found. The registered manager was responsive to the changing needs of the service and was challenging poor practice and guiding staff appropriately.

Records were easily accessible and accurate in relation to people at the home and for managing the regulated activity. The service’s training guide had been updated and accurately reflected the training which had been provided. The registered manager had an overall view of the training needs of the staff and was monitoring the training provided at the service. They recognised some staff had not completed the provider’s mandatory training and had plans in place to address this.

Staff were receiving appropriate support and professional development, supervision and appraisal. New staff were having a more robust induction and the service had started to use the new care certificate from Skills for Care. There were staff meetings, where staff had been informed of the actions being taken in relation to the CQC report. Staff were also asked their views about how to continually improve the service.

This is a summary of what we found.

This was a follow up inspection to look at required improvements which had been made in relation to care and welfare and staffing levels, following our previous inspection in June 2014. Following the inspection the provider sent an action plan to the Care Quality Commission (CQC) detailing the improvements being made.

We found improvements had been made and people living on the Pinnexmoor unit were having their social needs met. The registered manager had ensured there were enough staff on duty with procedures in place to ensure people received safe care from people with the appropriate qualifications, skills and experience required at all times. These areas are now compliant.

At the time of our inspection there were 52 people living at Ashdowne Care Centre. The care centre consists of two units known as Ashdowne House and Pinnexmoor. The Ashdowne unit provides nursing care for older people and the Pinnexmoor unit provides care for older people with dementia. There were 26 people living in the Ashdowne unit and 26 people living in the Pinnexmoor unit. One inspector visited the home and spent approximately five hours there. The focus of the inspection was on the Pinnexmoor unit. This was because at our last inspection June 2014 the concerns we identified had been on this unit.

During our inspection, we spoke with three visitors, the registered manager, the provider’s operations manager and nine staff. Due to most people living in the Pinnexmoor unit being unable to comment directly on the care they received we spent time in the communal areas observing people's experiences and how staff interacted with them.

As part of our inspection we looked at the activity records and care files of two people who were receiving support on the unit.

The questions we asked on this visit were:

Is the service safe?

Is the service caring?

Is the service effective?

Is the service responsive?

Is the service safe?

The service was safe because the registered manager had put into place procedures to ensure people were safe by having enough staff on duty with the appropriate qualifications, skills and experience required.

Is the service caring?

The service was caring because we observed staff treating people with kindness and respect.

Visitors told us “I am very happy with the care here” and “Very nice, X is well looked after, I have no concerns”.

Is the service effective?

The service was effective because the registered manager understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty safeguards (DoLS). They had made applications to the DoLS team for people with an assessed need in line with Deprivation of Liberty Safeguards legislation.

Is the service responsive?

The service was responsive to people's social needs. We saw people on the unit had a designated activity staff member. We saw people were engaged in meaningful activities. Staff interacted with people living at the home and were not always task orientated.

Documentation we saw showed every person in the unit had been engaged in personalised meaningful activities on a regular basis.

Staff we spoke with told us they had seen improvements. One member of staff told us “The changes have made it nicer to come to work” another said “It is much better but there is still room for improvement”.

We carried out an unannounced inspection visit at Ashdowne Care Centre in response to concerns raised from two sources about the quality of the care and alleged poor attitude towards people by a minority of care workers in the Ashdowne unit. These concerns were also shared with the local authority. As a result the provider was asked to investigate the allegations and report their findings back to the local authority adults safeguarding lead for consideration.

We were joined on our inspection visit by an expert by experience, provided to CQC though AgeUK. They spoke with people living at the home and visiting relatives about the experiences of people living there.

There were 45 people living at the home. 24 on Ashdowne and 21 on the Pinnex unit. We concentrated our observations on the Ashdowne unit and saw every person living in that unit. However, we also spent some time in Pinnex to and observed lunch and morning activities on that unit.

We met with the registered manager, the provider and the operations manager. We also spoke with a total of thirteen people and five visiting relatives. We met and spoke with nurses on duty, care workers and ancillary support staff. During the inspection we observed the activities coordinator interacting with eight people. We watched interactions between individual staff members and residents, including assistance with moving and handling and assistance given at mealtimes. We observed lunch being taken on both floors of the building.

We found a number of strengths at the home. Records, including care planning and risk assessment were completed very well and tailored to individual need. There were low incidents of falls and people received health care support from community based professionals when they needed this. Every person we spoke with summed the staff up as kind and caring. Food and nutrition appeared well organised and a range of specialised diets were catered for.

Cleaning staff were on duty. They struggled to prevent the development of pockets of malodour in the home in the Ashdowne wing. However, people were clean and well care for. One regular visitor to the home told us they noticed an odour each time they visited.

There was one activity worker, five days a week. On the Ashdowne wing the majority of people were nursed in bed, meaning people were often isolated. People received individual attention but this was often limited because of the demands upon care worker time in providing physical care support for people at the home.

Ashdowne Care Centre is located in the centre of a housing estate. It is divided into two distant areas joined by a walk-way. Each area has it's own staff team. One side works with people who have higher physical needs than the other side.

We spoke with a dozen people and with their relatives. Some people were confused as to where they were or why they now lived at the Care Centre. Everyone we spoke with told us how highly they rated the staff saying "I can't fault these people, I would not want you to think it" and "they are nice people". One women told us "yes I like it here, the staff are very good. They're kind, you can talk to them, they listen to you." A relative told us that they had looked at "every home in the district" and said "This is the best, the nurses are prepared to help - not just doing a job, they do appear to care."

We saw that the staff knew everyone well and could anticipate their needs. While we were there one person was celebrating their birthday. They had a family party with lots of visitors. Afterwards the person was tired and one member of staff stayed and supported them, gently chatting about the events of the afternoon.

There were 44 people living at the home when we visited. We spoke with six of the 23 people in Ashdowne, and with visitors to four people there who could not give us their views because of physical frailty or mental health needs. We spoke with five of the 21 people living in Pinnex and with five relatives. We spoke with 11 of the care staff.

People’s privacy, dignity and independence were respected. Their views and experiences were taken into account in the way the service was provided. One person said "I am very happy here, the staff leave me alone and let me do what I want. I have choices in everything I do. I get up early when I like and I have choices each meal time, and you can change your mind." There were effective systems to monitor the service's quality and manage risks to people, such as from unsuitable premises. A typical comment about the environment was "It’s clean and tidy.”

People experienced care that met their needs and protected their rights. For example, before they received care they were asked for their consent and where people did not have the capacity to consent the provider acted in accordance with legal requirements. We found the staff were supported to deliver care safely to an appropriate standard. Comments from people about whether their needs were met included “Oh yes, they notice if you’re a bit peaky” and “There’s always activities for residents.” One relative said ‘’Very happy here, wonderful care, the staff give all the care they need."

We carried out this unannounced inspection on 10 August 2012 in response to information of concern we had received. This centred on an allegation that one person’s health care needs had not been fully met and concerns about how people with dementia and associated behaviours were being treated. We therefore looked in detail at outcome four, in the unit that the concerns had been raised about. This was the Pinnex moor unit, the part of the home that provides care and support for people with dementia.

We spent time at the home talking to three people who currently live there as well as five members of staff and the management team including the registered manager and area director for the company. At the time of this inspection there were 24 people living at Pinnex moor unit with four care staff per morning shift, plus a nurse with three care staff in the afternoons and one nurse. We heard that there were three people being nursed in bed on this unit, due to their frail ill health.

We observed how care and support was delivered through some of the afternoon. Most people that live at this service had dementia and therefore not everyone was able to tell us about their experiences. To help us understand the experiences of people we used our SOFI (Short Observational Framework for Inspection) This tool allows us to spent time watching what is going on in a service and helps us record how people spend their time, the type of support they get and whether they have positive experiences. Some people using the service were able to tell us their views. We also spoke with one visiting relative and one health care professional following the inspection.

We looked at some of the key records kept by the home. These included care plans, risk assessments and accident and incident reports. This helped us to better understand how well the home was run.

People we spoke with who were able to share their experiences of living at the service were very positive. Comments included ‘‘I wouldn’t stay here if I didn’t like it.’’ ‘‘It seems very nice, I think it is a good place to be.’’ One visiting relative told us they, and other family members visit on a regular basis and said ‘‘Even if I won the lottery I wouldn’t move XX, the care is so good here.’’ We spoke with one health care professional following the inspection and were told that they had no concerns about the care and support provided at the home. We heard that they had provided advice and support to the staff and that the unit had provided good care and support for people with complex needs.

We looked at how well care and support was planned and reviewed. The plans contained good basic information about what personal, health and emotional care needs people had and how staff should meet these needs. Risk assessments were in place to show how the home identified managed and minimised any risks for people. Plans also included details about people’s social history and their likes and dislikes. We saw that although one person’s weight had been closely monitored, and their care plan reviewed monthly with comments about their weight loss, the follow up to health care professionals had not been pursued in a timely fashion. This meant that the person did not get access to health care in put in a timey way.

We observed staff providing care and support in a kind and sensitive manner and we were told by staff that they felt well trained and supported to do their job.

We observed people experiencing positive interactions with staff trying hard to engage people. We saw that there were planned activities for each day and that there were baskets of stimulating objects for people to rummage through in the lounge. We saw that where someone was becoming agitated, staff used diversionary tactics to redirect the person to a more positive interaction with staff.

We made an unannounced visit to Ashdowne Care Centre on 26 January 2012. We spent one day at the service. We looked at the care and support people received in the Pinnex Moor House; this unit cares for people who have dementia or other mental health conditions. We targeted our inspection in this unit as this had been the area where concerns identified at our previous inspection had been centred. We also went to the sister unit on-site, where people who have general nursing needs live. We toured the building there and spoke with two people who said they received good care.

On the day of our visit 21 people were living in Pinnex Moor House. They were supported by a nurse, three care workers, and three ancillary staff. Both the manager and a senior nurse came in on their days off to assist with the inspection when they were made aware that we were at the home.

People living in Pinnex Moor House were unable to talk to us to tell us about their experience of living there. However, we observed their moods and activities during the day and we found that people appeared comfortable and relaxed. Two relatives told us that their spouse/partner received good care in the unit.

We found that the provider had met the three compliance actions made in our previous inspection report. At this inspection we also looked at one additional outcome relating to cleanliness and infection control. We have made two improvement actions as a result of this follow-up inspection. They are with regard to ensuring that people are meaningfully occupied throughout the day and to make sure that care records are effectively evaluated so that people’s needs will be met. We have asked the provider to send us an action plan stating how they will act on these issues.

We were not able to speak with people who live at the home due to their level of dementia. However, we carried out a SOFI (Short Observational Framework for Inspection) that enabled us to observe the experiences of the individuals living in the home.

We found that whilst staff spoke kindly to people, there was little interaction or conversation that did not centre around tasks. People who were not involved in personal tasks and those who were not calling for attention were largely ignored.

We carried out an unannounced comprehensive inspection on 26 February 2015 and 6 March 2015. We had decided to bring forward a planned inspection because we received two alerts from the local authority safeguarding team regarding people at the home developing skin damage which could have been caused by poor care management and two concerns about the  skills of the staff at the home.

Ashdowne Care Centre is registered to provide accommodation with nursing or personal care, for up to 60 people. The service is intended for older people, who may have needs due to dementia or other mental health needs. The home is divided into two units, Ashdowne and Pinnexmoor, with each area having its own staff team. The two units are joined by a link corridor. There were 53 people living at the home at the time of our inspection.

There was 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.’

We last inspected the home in October 2014 to follow up actions taken by the provider following breaches in the regulations we found at an inspection in July 2014. At that inspection we found improvements had been made to people’s care and welfare and the staffing at the home. This meant the service was meeting all the regulations inspected.

People received most of their prescribed medicines on time and in a safe way. However, some improvements were needed in management of topical creams and ointments.

People’s needs were assessed but improvements were needed to ensure all care plans and risk assessments were regularly reviewed so staff were provided with the detailed information they needed to deliver consistent and appropriate care. People and their representatives were not actively being involved with making decisions about their care but relatives were being kept informed of any changes and concerns.

Where people did not have the capacity to consent or make decisions, the provider had not acted in accordance the Mental Capacity Act (2005) and Deprivation of Liberty safeguards. There were no mental capacity assessments for people who lacked capacity. This meant staff did not have information to assist people to make decisions for themselves. Staff were seeking consent from relatives for people who they assumed lacked capacity. There was no records of ‘best interest’ decision making to show how people, relatives and other professionals were consulted and involved in decision making about people’s care and treatment.

CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS). Seven applications had been made to deprive people of their liberty and the registered manager was prioritising the assessment of other people at the home to consider whether any further applications were required.

People were at risk of being socially isolated because they were not being given the choice to come out of their rooms and use the communal areas at the home. Activities were provided at the home but there were long periods of time when meaningful activities were not happening and people isolated in their rooms were not able to access the activities at the home.

Improvements in staff training were needed to ensure staff were supported to acquire and maintain skills and knowledge to meet people’s needs effectively and safely. The majority of staff had not received training in MCA and DoLS. Staff did not receive formal supervision and appraisal so they did not have the opportunity to express their views and concerns and to identify their training needs. Staff recruitment processes were safe and there were enough staff employed to meet the needs of people in the home.

Quality assurance and audit processes were in place to help monitor the quality of the service provided. The provider had an operations manager who visited the home and monitored the quality of service to identify, assess and manage risks relating to people’s health, welfare and safety. However they had not recognised or dealt with all of the identified shortfalls found at this inspection.

Improvements were required to ensure systems and processes were in place to protect people’s rights, to ensure they were supported by staff who had received appropriate training and supervision and to make care more personalised and accurate to people’s individual needs. The provider did not regularly seek the views of people using the service and staff. Relatives and representatives and health professionals were asked annually to complete a quality assurance questionnaire for their views on the service.

The premises were well managed to keep people safe. At this inspection staff were aware of signs of abuse and knew how to report concerns and were confident these would be investigated. Staff working at the home knew people’s needs and preferences well and people and relatives said staff were caring and kind. There were friendly and respectful interactions between staff and people. People were supported to have suitable and sufficient food and drink.

We found four breaches of Regulations in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The action we have asked the provider to take can be found at the back of this report.