This inspection took place on the 21, 26 and 29 November 2018. The first day of the inspection was unannounced, and started at 07:30am to allow us to meet with the night staff, be present at the staff handover and see how duties were allocated for the day.

Ashfield is a ‘care home’ without nursing, operated by South West Care Homes Limited. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

People living at Ashfield were older people, many living with long term health conditions or dementia. The service accommodated up to 25 people in one adapted building, with a chairlift to access the rooms on the first floor. 22 people were living at the service at the time of the inspection, with one other person in hospital.

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 2008 and associated Regulations about how the service is run.

At the last inspection of the service on 5 and 10 January 2017 the service was rated as ‘good’ in all areas. On this inspection we found this had not been sustained and we have rated the service as requires improvement overall. The key questions for Safe and Well led have been rated as requires improvement. The service had identified many of the issues we had found, and taken or were planning to take some actions to address risks to people. However, we could not be assured the actions they planned to take would be effective in mitigating the risks as they were not all in place. These concerns did not yet give us confidence governance was reliable and effective, because many changes were still ‘work in progress’.

We also asked the service to make a safeguarding referral as we were concerned medical advice had not been sought in a timely way for one person after an accident. This was being looked at by the safeguarding team from the local authority.

There were enough safely recruited staff on duty to meet people’s needs. Staff had not all competed their training according to the service’s training matrix. However, staff and people told us they felt they had the skills and knowledge to support people effectively and had access to senior staff for advice and support. Systems were in place to learn from accidents or incidents and for staff supervision.

People received their medicines as prescribed. We have made recommendations in relation to the management of medicines and competency assessments for staff. We have also recommended that the service ensures they contact people’s GP and record this after any admission or re-admission to verify if any prescribed medicines had changed since their last visit or the pre-assessment was completed.

People were protected from abuse. Staff understood what constituted abuse and were aware of how to report concerns about people’s wellbeing. People told us they ate well and enjoyed their meals.

Care plans contained sufficient detail to enable staff to respond to people’s needs in a person-centred way. We saw staff understood how to support people in ways that made use of known information about the person’s history and choices. Risk assessments were in place to support people for example with pressure damage, choking risks, poor nutrition, falls and moving and positioning.

People’s rights with regard to the Mental Capacity Act 2005 were well understood. Where Deprivation of liberty authorisations (DoLS) had been granted, conditions of the DoLS were well understood. This meant people’s rights were being supported.

Ashfield is a long established care home, set in a converted period building in a residential area of Exmouth,

This inspection took place on 5 and 10 January 2017. The first day of our visit was unannounced. Our second visit was announced so that arrangements could be made for us to spend time with the responsible person and registered manager.

Ashfield provides accommodation and 24 hour care for up to 25 older people. There were 20 people living at the home on the first day of our inspection. One of these people was in hospital and one was staying at the home for a short period of respite.

We had previously carried out a comprehensive inspection of this service in June 2015. Four breaches of legal requirements had been found at that inspection. These were regarding medicine management, notifying required events to the Care Quality Commission (CQC) that had taken place in the home, complaints management and reviewing people’s care needs. We returned and undertook a focused inspection in December 2015 to look at the actions taken to improve the medicine management at the home. We found improvements had been made and the service was no longer in breach of Regulation 12 which relates to medicine management. We did however make a recommendation to the provider about the management of medicines at the home.

At this inspection we found they had taken action and medicines were safely managed. We also looked at this inspection at the other three breaches found in June 2015. We found action had been taken regarding these concerns and the requirements had been met.

There was a registered manager at the service who registered with the Care Quality Commission (CQC) in January 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. The registered manager was very visible at the service and undertook an active role. They were committed to providing a good service for people in their care and demonstrated a strong supportive approach to people, their relatives and staff. They were supported by the responsible person and the provider’s operational team who visited regularly.

There were sufficient numbers of suitable staff to keep people safe and meet their needs. The registered manager had increased the staff levels at the service since our last visit. They continued to monitor people’s needs and adjusted the staff levels as required. Staff undertook additional shifts when necessary to ensure these were maintained.

Staff demonstrated an understanding of their responsibilities in relation to the Mental Capacity Act (MCA) 2005. They understood where people lacked capacity, a mental capacity assessment needed to be completed with best interest decisions made in line with the MCA. They had submitted applications where required to the local authority Deprivation of Liberties Safeguarding team (DoLS) to deprive some people of their liberties. Staff had a good understanding about giving people choice on a day to day basis. The registered manager and senior staff had received MCA training to help them understand their responsibilities. Plans were in place for other staff to undertake MCA training.

People were supported by staff who had the required recruitment checks in place. Staff had received an induction. Staff had completed the provider’s mandatory training. They were also supporting staff to undertake higher qualifications in health and social care.

Staff had completed safeguarding training and were knowledgeable about signs of abuse and how to report concerns. Staff felt confident any concerns they raised would be investigated and actions taken to keep people safe.

People were supported to eat and drink sufficient amounts and receive a balanced diet. The provider’s new computerised recording system enabled an accurate recording and monitoring of people’s diet and fluid intake. People

We visited the home on 22 December 2015 for a focused unannounced inspection to look at medicines handling in response to concerns found at our previous inspection.

The home was providing a service to 19 people on the day of our visit.

We carried out an unannounced comprehensive inspection of this service on 12 and 17 June 2015. At the June inspection we identified three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This inspection in December 2015 was to check whether they had met the legal requirements of Regulation 12 (2) g of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, which relates to the proper and safe management of medicines. This is part of one of the five questions we ask about services: is the service safe? It was an unannounced focused inspection by a medicines inspector – pharmacist.

We found that there had been improvements to the way medicines were managed in the home. Further improvements to ensure that medicines were safely handled were being planned but had not yet been fully implemented at the time of this inspection. These included changes to staff training and checking, medicines storage and records, and medicines auditing systems.

We have made a recommendation about the management of medicines.

The focus of the inspection was to answer a key question in relation to a concern we received: is the service safe? The concern related to staffing levels and the expected role of night staff and whether people’s needs were met at night.

Before our inspection we reviewed all the information we held about the home. We examined previous inspection reports and notifications received by the Care Quality Commission. The service was last inspected in July 2013 and Outcome 13: Staffing was found to be compliant.

On the day of our visit there were 25 people living at Ashfield. We looked at the care files of four people with complex needs who may require assistance at night on occasions. We spent time with people in the lounge and observed their care. We spoke to the manager who was applying to be registered with CQC and three care staff to find out if the care and services people received met their needs, particularly at night. All the people we spent time with were unable to tell us their experiences directly due to living with dementia.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

Is the service safe?

The service was safe because people’s health and care needs were understood and met by a trained and supported staff. Risks to people’s health and welfare were understood and managed in line with their agreement. The manager told us they had recently worked some night shifts as part of ongoing monitoring and had not found any issues with staff provision at night. Staff were able to discuss any issues during regular one to one supervision sessions. There was monitoring of events and incidents and measures were put in place minimise any identified risks such as falls and skin damage.

People’s health and well-being was promoted. Care plans provided instructions to staff about the care each person wanted and needed. Staff were very knowledgeable about people’s individual needs and there were comprehensive night time care plans showing exactly how the person’s needs were met at night. We saw evidence of multi-professional visits and appointments in a timely way, for example GP, speech and language therapist, and community psychiatric nurses and that advice was followed and recorded. Care plans included considerations of the Mental Capacity Act (2005) such as best interest decision making and staff demonstrated an understanding of the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards (DoLS) and how they applied to their practice. We found the location to be meeting the requirements of the Mental Capacity Act (2005). People’s human rights were therefore properly recognised, respected and promoted and appropriate family/advocates were involved.

We had previously inspected Ashfield on 15 and 16 may 2013. We had found then that improvements were needed to ensure that people's dignity was protected, care files were up to date and that people consistently received their planned care. Some fixtures and equipment were unsafe or unsuitable. There had been insufficient staff to meet people's needs and quality assurance systems had not been effective.

When we visited on 17 July 2013 we found that the provider had taken prompt and robust action and was meeting required standards.

We observed that people were treated with dignity and respect. There had been substantial improvements in updating of care plans and in the quality of recording in those plans. The provider had been pro-active in working with health professionals to make improvements.

20 people were living at Ashfield during our latest inspection. We spoke with ten of those people. They told us that care workers treated them well. Comments included, "They are kind and I don't have any complaints" and "They are polite to me". A relative we spoke with on the telephone told us, "The staff are very kind".

There had been improvements to the environment and layout of communal areas of the home. New equipment had been purchased and was in use. Some fixtures and fittings had been replaced.

Rotas showed that additional staff were used at busy times and the organisation of work had improved. Quality monitoring systems were more effective and were evolving.

We, the Care Quality Commission, visited the home unannounced on the 25th May 2012. Prior to this visit we had received some concerns about the home. These related to moving and handling of people, medication recording, poor nutrition, infection control practices, the environment and people being left in their beds unable to access their call bells. We did not find the majority of the concerns substantiated, however we have pointed out some areas for improvement to the provider in relation to staff training and supervision, care planning and the environment.

On our visit we spoke with 9 out of the 23 people living at the service. We also spoke with 2 relatives or supporters of people living there. People told us overall that their needs were met, and that they were happy with the services they received. One person told us "I take the Telegraph and I can't believe the terrible things I read about care homes. I am really happy here." Another person told us "I think we are very very lucky to be looked after so well as we are". One person told us they were "happy enough, however staff sometimes don't remember things and we have to ask again and again". A relative we spoke to told us that they knew the home was right for their mother as soon as they walked in the door. they said they had seen several other homes but Ashfield was the one they had chosen.

We saw people going out of the home with paid carers, volunteers from a local charity or friends during the course of the day. One person went out unescorted to a local bookmakers. Other people had visitors or spent time in their rooms or in communal areas. One relative we spoke to told us their mother spent much of her time in her room from her personal choice, and did not wish to mix with other people. During the day there were activities being provided in house by care staff and a visiting activities organiser. One person we spoke to told us they always had the door to their room open so they could see what was going on, but did not want to "join in with the crowd" in the lounge.

People we spoke with told us that they had good relationships with the staff and that if they had any concerns they would tell their relatives or the manager.

We saw people being given their medication as a part of a medication round. People were given time to take their tablets with an explanation if needed of what they were for. However we found a tablet on the floor of the dining room when we arrived at the home that had been partially consumed.

People we spoke with told us the staff were very good and met their needs well. They told us that they generally felt there were enough staff on duty and that people responded when they rang the call bells, although it might take some time at the busiest times in the day.

An unannounced inspection took place on 12 and 17 June 2015. It was carried out by two inspectors. Ashfield provides accommodation and 24 hour care for up to 25 people. There were 19 people living at the home on the first day of our inspection. On the second day, a further two people were temporarily staying at the home to provide respite for their carers.

A registered manager was not in post as they had resigned in February 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’. There was a new manager who had just started working at the home and was in the process of registering as a manager with CQC. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The Care Quality Commission (CQC) is required to monitor the operation of the Mental Capacity Act (2005) (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are put in place to protect people where they do not have capacity to make decisions and where it is considered necessary to restrict their freedom in some way, usually to protect themselves or others.

At the time of the inspection, three applications had been made to the local authority in relation to people who lived at the service; the DoLS team had not been updated regarding a change to one person’s circumstances which would have escalated their case to be reviewed. The new manager told us they would be reviewing people living at the home to see if further applications needed to be made.

Improvements were needed to manage some risks to some people’s safety and well-being. There were not always sufficient numbers of staff on duty in communal areas to meet people's needs at some mealtimes. People’s medicines were not always managed safely. Improvements were needed to reduce environmental and infection control risks.

Improvements were needed to ensure staff received regular supervisions and appraisals. Some staff needed further support to enhance their practice. The layout of some communal areas could be improved to enable people to have more space to move around. It was not clear if care plans were written in conjunction with individuals and their representatives.

People’s individual care needs were assessed but reviews had not recently taken place to ensure people’s care needs were met and people were happy with their care. Improvements were needed to record, manage and respond to complaints.

There were quality assurance systems in place to monitor, identify and manage the quality of the service but there were areas that needed to be improved to make them more effective to ensure people experienced a high standard of care. CQC were not always informed of notifiable events that had taken place in the home.

We found a number of 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.

However, there were also aspects of care that supported people’s safety and well-being. Staff who worked at the service had generally undergone a robust recruitment process and knew how to recognise and report allegations of abuse.

People were supported to make decisions about their care and support and staff obtained their consent before support was delivered. Staff knew their responsibility under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. People were supported to access healthcare services to meet their needs. People’s nutritional needs were monitored.

People were treated with dignity and with kindness and respect. Staff understood people’s individuality and communicated effectively with them about their support. People were asked about their preferences and activities were arranged in the home.