This inspection took place on the 5 and 6 January 2017 and was unannounced.

At the previous comprehensive inspection on 27 and 30 October 2015 there were breaches of legal requirements. For example, we found risk assessments were not always reflective of people’s needs and care plans were not reflective of the care being given. There were not always suitable numbers of staff deployed to meet people’s needs, people did not have end of life care plans in place and although accidents and incidents were recorded, they were not always audited to look for themes to reduce the likelihood of a reoccurrence. We asked the provider to send us an action plan on how they would meet these requirements. We also found the provider's systems to monitor the quality of service people received were not effective. Enforcement action was taken on this issue. After the comprehensive inspection the provider wrote to us to say what they would do to meet the legal requirements in relation to our enforcement action. We undertook a focused inspection on 29 February 2016 to check they had followed their plan and to confirm they now met legal requirements. We found the legal requirements were being met.

Asheborough House Care Centre is a nursing and residential care home which predominately provides nursing care and support to people who have been diagnosed with a form of dementia. The home is registered to accommodate up to a maximum of 31 people. At the time of the inspection, there were 27 people living at the service.

There was a registered manager in place. 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.

People were well cared for at Asheborough House. One staff member told us; “I can one hundred percent say that every resident here is so well looked after”. Staff were exceptionally kind, caring and compassionate and the interactions we observed were warm, affectionate and caring. People’s dignity was upheld and their confidential information was securely stored.

Without exception, people and their relatives told us the service was very caring. One relative said; “They go above and beyond their duties all the time”. Staff were extremely caring and treated people with kindness, compassion and affection. The service was committed to delivering outstanding end of life care, in which people’s wishes were respected and where people experienced a pain free, dignified death.

There was a strong focus on delivering innovative, personalised activities for people. There was a commitment to forging links with the local community and ensuring people remained visible and active whether in the service or in the community.

Relatives were made to feel important and were always warmly welcomed at the service. Staff and managers were considerate towards them and ensured that they felt looked after and valued. Relatives were kept informed of any changes and were able to have an open and honest dialogue with staff and managers. Relatives felt able to approach the managers with any issues and their feedback was sought and valued.

Systems were in place to deal promptly and appropriately with any complaints or concerns. The registered manager promoted the ethos of honesty, learning from mistakes and admitted when things had gone wrong. This reflected the requirements of the Duty of Candour. The Duty of Candour is a legal obligation to act in an open and transparent way in relation to care and treatment. Feedback on the service was sought in creative ways to ensure everybody had their voices heard.

The service was well led. The registered manager valued their staff, paid attention to detail and led by example. They were committed to continuous improvement and development. All of

We carried out an unannounced comprehensive inspection of this service on 27 and 30 October

2015. Breaches of legal requirements were found and enforcement action was taken. This was

because the provider's systems to monitor the quality of service people received were not effective.

After the comprehensive inspection the provider wrote to us to say what they would do to meet the

legal requirements in relation to our enforcement action. We undertook this focused inspection on

29 February 2016 to check they had followed their plan and to confirm that they now met legal

requirements. 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 Asheborough House Care Centre – Saltash on our website at www.cqc.org.uk.

Asheborough House Care Centre – Saltash provides nursing and residential care for up to 31 older

people who require support in their later life or are living with dementia or mental ill health.

There were 28 people living at the service at the time of this inspection. The home is on three floors, with access to the lower and upper floor via stairs, a lift or chair lift. All bedrooms have wash hand basins. There are shared bathrooms, shower facilities and toilets. Communal areas include three lounges, and one dining room. There is a garden for people to use when they wish to.

The service had not had a registered manager since August 2015; however an application for a new manager had been made and was in process. 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.

Monitoring systems had been devised, implemented and improved to help ensure the quality of care people received was effective and met their needs. A quality assurance policy had been created to reflect the new processes which were in place, and other polices had been written to support the new quality auditing systems. Records showed one of the directors had also been visiting the service to meet with the manager, to discuss the operation and delivery of the service. This helped to support the manager with the leadership of the service and to promptly identify when the manager may require support. People, their family and loved ones were being encouraged to be part of the creation of their care plan and with care planning reviews.

The manager had been working positively with the local authority service improvement team, to complete an action plan which had been put into place, following our last inspection.

We gathered evidence against the outcomes we inspected to help answer our five key questions: Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led? The people who lived at Asheborough House had a dementia and therefore not everyone was able to tell us about their experiences. To help us to understand the experiences people had we used our SOFI (Short Observational Framework for Inspection) tool. The SOFI tool allows us to spend time watching what is going on in a service and helps us to record how people spend their time, the type of support they get and whether they have positive experiences. We also spoke with a psychiatric nurse (CPN) who was visiting on the day of our inspection.

This is a summary of what we found-

Before our inspection we received some anonymous information of concern about the service. The information related to the care and welfare of people, with regards to staff not treating people with dignity and respect.

As part of our inspection we met with the registered manager of the service, the matron who took clinical responsibility for the service and with the nurse on duty. We also spoke with care staff and domestic staff who were working on the day of our inspection.

Is the service safe?

At the time of our inspection we did not find the service to be safe.

People’s needs were assessed, but care and treatment was not always planned and delivered in line with their individual care plan. The care home provided care for people who predominately had a diagnosis of dementia or mental health, however, we observed that basic knowledge regarding dementia care was absent from the care and support people were receiving.

Is the service effective?

At the time of our inspection we did not find the service to be effective.

Where people did not have the capacity to consent the provider acted in accordance with legal requirements.

The Care Quality Commission monitors the operation of the Deprivation of Liberty Safeguards (DOLs) which applies to care homes. The recent judgement made by the Supreme Court on 19th March 2014 places a responsibility on providers to ask two key questions; is a person subject to continuous supervision/control? and is the person free to leave? If a person does not have capacity and is subject to both continuous supervision/control and not free to leave, then a person is being deprived of their liberty. We found there was a code on the front door to the home which was displayed, which meant people who lived at Asheborough House, who had mental capacity, were able to come and go as they pleased. For others, who had been professionally assessed as not having mental capacity documentary evidence was in place in peoples care plans. We found that not all staff were trained in the DoLS and people were not always asked for their consent before staff assisted them.

People were not cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard. We found that the system for staff supervision and appraisal was sporadic which meant staff were not always given the opportunity to discuss their training requirements or to discuss positive and critical aspects of their working performance. We found that essential training applicable to individual staffing roles was not always carried out.

Is the service caring?

At the time of our inspection we did not find the service to be caring.

Peoples’ privacy, dignity and independence were not respected. People’s views and experiences were not taken into account in the way the service was provided and delivered in relation to their care. From our observations and from reading documentation, people who lived at Asheborough House were not always treated like individuals. We saw a mixed approach by staff in the way they involved people and showed respect to people. Some staff that we saw working with people showed through their actions, empathy towards the people they cared for, whilst others did not.

Is the service responsive?

At the time of our inspection we did not find the service to be responsive.

We looked at people’s care plans. A care plan is a document which provides direction and guidance to staff about how to meet a person’s care needs. We saw from people’s care plans that social activities and the encouragement of stimulation was lacking.

We were told by the manager that the home had three registered mental health nurses (RMN’s) currently employed. One RMN worked during the day, and one RMN worked at night. The senior RMN was on leave and would be returning in November 2014. The clinical matron confirmed that they were currently “top heavy” with registered general nurses (RGN’s). An RGN and RMN are both qualified nurses, but work in different fields, for example RGN’s work in general health whilst RMN’s specialise in psychiatry.

Care plans and associated risk assessment documentation was well ordered. We found care plans to be detailed with regards to clinical care needs. However, care plans did not always give specific guidance and direction about how to meet a person’s needs.

Is the service well-led?

At the time of our inspection we did not find the service to be well-led.

The provider had a manager who was registered with the Commission. The provider did not have an effective system to regularly assess and monitor the quality of service that people received. People who used the service, their representatives and staff were not asked for their views about the care and support they received.

We met most of the people who used services, spoke to two visitors and talked with the staff on duty and checked the provider's records.

We saw people’s privacy and dignity being respected at all times. We saw and heard staff speak to people in a way that demonstrated a good understanding by staff of people’s choices and preferences.

Staff were clear about the actions they would take should they have any concerns about people's safety.

We saw that people's care records described their needs and how those needs were met. We saw that people's mental capacity was assessed to determine if they were able to make particular decisions.

During our visit to the home we saw sufficient staff on duty to meet the needs of people living in the home. We spoke with most of the staff working during our visit and all agreed that the home had sufficient staff.

We saw that Asheborough House Care Centre held all records securely to protect people’s confidentiality.

We conducted an unannounced, visit to Asheborough House Care Centre and spoke to seven people who used the service. People told us "The staff are kind"; "I really like it here"; "Happy as a lark”. No person using the service could think of anything which could be improved.

The people using the service had complex needs which meant they were not all able to tell us their experiences. Because of this we used a number of different methods to help us understand the experiences of people using the service. This including observation and talking to staff.

An agency staff working at the home said, “It’s a lovely home and everyone works as a team”.

We saw that people were involved in decisions about their care and treatment.

People’s needs were not always met because whilst staff were available in sufficient numbers, some staff lacked the skills and knowledge about dementia care to ensure people’s needs were met. This may have been due to few staff having completed dementia training;

We saw that staff did not always treat people with respect and people were left for long periods without any interaction.

There was a good provision of equipment and the home was very clean and fresh. The home employs an activities co-ordinator and staff had time to spend with people, however they each spent time with the same few people throughout our visit.

People, who were able to, told us that the staff were kind and helped them to make decisions about the times they got up and went to bed. For those people not able to speak with us, we undertook a Short Observation Framework for Inspection (SOFI). This means that we sat and watched what happened, what people were doing and any contact they had with staff or other people. We did this in the main lounge area, after the evening meal to see what it was like to live at the service. We saw that staff spent time with people using the service and interacted well. Staff spoke with people in an respectful and considerate manner and helped them to take part in some activities, such as looking at books.

People, who were able, told us that the staff were kind and supportive. They told us that they had some input into the routines of their day and they were offered choices about how they spent their time, the food they ate and some aspects of the care they received.

For those people not able to speak with us, we undertook a Short Observation Framework for Inspection (SOFI) in the main lounge area, to see what it was like to live at the service. We saw that some staff spent time with people using the service and some staff were more task focused and did not spend time with people. We saw that some people had limited or no interactions with staff and other people living at the home.

For those people not able to speak to us, we undertook a Short Observation Framework for Inspection (SOFI) in the main lounge area, prior to lunch, we wanted to know what it was like to live at the service. We saw that people were spoken to in a respectful manner and staff took time to listen to their responses and acted appropriately.

We saw that people were offered choices and that some people were supported with some recreational activity.

This was an unannounced inspection on 27 and 30 October 2015. Asheborough House Care Centre – Saltash provides nursing and residential care for up to 31 older people who require support in their later life or are living with dementia or mental ill health.

There were 28 people living at the service at the time of our inspection. The home is on three floors, with access to the lower and upper floor via stairs, a lift or chair lift. All bedrooms have wash hand basins. There are shared bathrooms, shower facilities and toilets. Communal areas include three lounges, and one dining room. There is a garden for people to use when they wish to.

The service had not had a registered manager since August 2015; however an application for a new manager was in process. 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 October 2014 we told the provider to take action to make improvements to how they ensured staff were formally supervised, and to how they assessed and monitored the quality of the service people received. The provider sent us an action plan confirming how improvements were going to be made. During this inspection we looked to see if these improvements had been made. We found they had not all been completed.

People received care and support from staff who were kind and caring, and treated them with respect. Relatives told us they were happy with the care their loved ones received. People and their relatives told us there were enough staff. However, on the first day of our inspection we were told by staff, and observed, there were not enough care staff on duty. Some people did not receive their breakfast until 11.30am and some people were still being assisted out of bed at 12 noon. People who required assistance at lunch time, were not always given it or had to wait whilst others finished their meal, before being supported. Social activities did not always take place which meant people did not have much to occupy their time.

People did not live in an environment which promoted the principles of good dementia care because of poor signage and a lack of colour contrast. Although the environment was clean and free from malodours, people were not always protected by effective infection control procedures because staff did not always display knowledge of infection control practices.

People were supported to eat and drink enough and maintain a balanced diet. The chef was knowledgeable about people’s individual nutritional needs. People who required assistance with their meals were supported in a kind way. People’s care plans provided details to staff about how to meet people’s individual nutritional needs. People who were at risk of losing weight were not always effectively monitored; however the manager took immediate action to resolve this.

People felt safe. The manager and staff understood their safeguarding responsibilities and had undertaken training. People were protected by safe recruitment procedures as the manager ensured new employees were subject to necessary checks which determined they were suitable to work with vulnerable people.

People were not always protected from risks associated with their care because staff did not have the correct guidance and direction about how to meet people’s individual care needs. Accidents and incidents were not robustly analysed to help prevent them from occurring again. People had personal evacuation plans in place, which meant people could be effectively supported in an emergency.

People’s mental capacity was assessed which meant care being provided by staff was in line with people’s wishes. People who were deprived of their liberty had been assessed. The registered manager and staff understand how the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DoLS) protected people to ensure their freedom was supported and respected. The MCA provides the legal framework to assess people’s capacity to make certain decisions, at a certain time. When people are assessed as not having the capacity to make a decision, a best interest decision is made involving people who know the person well and other professionals, where relevant. DoLS provide legal protection for those vulnerable people who are, or may become, deprived of their liberty. People’s consent to care and treatment was obtained, and staff asked people for their consent prior to supporting them.

People did not always have care plans in place to address their individual health and social care needs. People’s care plans were not always reflective of the care being delivered. People were not involved in the creation of their care plan. Nursing records were not always reflective of people’s care plans. People’s changing care needs were not always communicated to help ensure prompt action was taken. External health professionals did not have any concerns and explained they were contacted appropriately when required.

People were cared for at the end of their life. Nursing staff had good links with GPs to help ensure people’s care was effectively co-ordinated. People’s end of life care and resuscitation wishes had not always been recorded so staff would know what to do at the end of a person’s life to ensure they received the care they wanted. The manager told us she would be making improvements. People’s medicines were managed safely.

People’s confidential and personal information was stored securely and the manager and staff were mindful of the importance of confidentiality when speaking about people’s care and support needs in front of others.

People and those who mattered to them were encouraged to provide feedback about the service they received. People told us if they had any concerns or complaints they felt confident to speak with the staff or manager. People received care from staff that had been given training and supervision to carry out their role. Staff felt the manager was supportive. Staff felt confident about whistleblowing and told us the manager would take action to address any concerns.

The provider did not have effective systems and processes in place to ensure people received a high quality of care and people’s needs were being met. The Commission was not always notified appropriately, for example in the event of a serious injury. The manager had an ethos of honesty and transparency. This reflected the requirements of the duty of candour. The duty of candour is a legal obligation to act in an open and transparent way in relation to care and treatment.

We recommend the provider considers research and published guidance in relation to the design of the care home environment and its connection in providing an enhanced level of care for people living with dementia.

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