About the service: Ashleigh Manor Residential Care Home (“Ashleigh Manor”) is a residential care home that was providing personal and nursing care to 43 older people and younger adults and over at the time of the inspection. They are registered to accommodate 65 people.

People’s experience of using this service:

•The quality of people’s care continued to raise serious concerns.

•People dependent on staff to pre-empt and meet their needs were being failed by the service.

•People were not receiving care that was fully safe, effective, caring, responsive to their needs and well-led.

•The service is now judged to be inadequate in keeping people safe, providing effective care as well as continuing to be inadequately well-led.

Rating at last inspection: The rating at the last inspection was Requires improvement overall. The report was published on the 8 August 2018. This service had been rated repeat Requires improvement at the previous two inspections. They were last rated as Good in 2015.

Why we inspected: We inspected in line with our inspection methodology. This was within six months of publication as the service had been judged to be Inadequate in well-led at the last inspection. Prior to this inspection, the service was also placed into whole home safeguarding by the local authority due to a number of concerns in respect of people’s care. CQC have been liaising closely with the local safeguarding adults team. The areas of concern were used to inform our planning for this inspection.

Enforcement: Following our last inspection we added positive conditions to the provider’s registration. This required them to report to us each month to ensure we could monitor their progress. On this inspection, we found some conditions were met and others were not. Whilst some elements of the conditions had been met this had not led to sustained improvements and in many areas, we identified deterioration in people’s care.

In respect of this inspection, full information about CQC’s regulatory response to the more serious concerns found in inspections and appeals is added to reports after any representations and appeals have been concluded.

Follow up: The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

The inspection of Ashleigh Manor Residential Care Home (“Ashleigh Manor”) took place on the 15 and 16 May 2018 and was unannounced. We carried out this inspection as a responsive comprehensive inspection due to concerns we had shared with us about the service. This included information from whistle blowers and following a review of our records in line with our intelligence monitoring. Details of how we monitor Adult Social Care Services that are registered with us can be found on our website at: http://www.cqc.org.uk/guidance-providers/adult-social-care/how-we-monitor-inspect-adult-social-care-services

Our information raised concerns about the number of falls resulting in injury, medicine errors, how people’s continence care was being managed and moving and handling practices.

We were told there was not enough staff or the right equipment to meet people’s needs. Also, people’s medicines were not being fully signed for, people were not having their prescribed creams put on their skin and people’s continence needs were not being met. Staff were also not reading care plans so were unaware of people’s needs and preferences.

In addition, there were concerns about staff were not speaking to people, staff not wearing gloves and aprons as they should and staff were not passing concerns on to management and complaints were not being dealt with appropriately.

When we completed our previous inspection on 27 and 28 September 2017 we found concerns relating to staffing levels; gaps in medicine records; people’s care plans not fully reflecting their care; activities not being personalised and the provider was not ensuring the quality of the service. This meant we rated the key questions of Safe, Responsive and Well-led as Requires improvement. Effective and Caring key questions were rated as Good.

We requested the provider to tell us in an action plan how they were going to put right the concerns in respect of breaches of Regulations for staffing the service safely; assessing, monitoring and improving the quality of the service and in ensuring people’s records were complete and accurate.

Ashleigh Manor 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.

Ashleigh Manor can accommodate 65 people in two separate parts of the premises. These are known as ‘The Manor’ and ‘The Lodge’. Historically, people in The Manor are living with dementia or complex needs and people of reduced complexity lived in The Lodge. However, on this inspection we found people had complex needs in both parts. When we inspected, there were 51 people living at the service. The Manor had 25 people living there and 26 in The Lodge.

A registered manager was not currently in place in respect of this service. However, the current manager was in the process of registering with us. 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. They were supported in running the service by a care manager, two administrators and one of the registered partners/provider. One of the provider’s daughters acted on behalf of the registered provider during the inspection with the main partner/provider attending the second day of the inspection.

On this inspection, we reviewed the concerns we had received and checked to see if the provider was compliant following the last inspection. We found some improvements had been made in some areas but we also found continued concerns and some new concerns that are summarised below.

Staff described the lack of staff and equipment as the two main issues impacting on people.

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Ashleigh Manor Residential Care Home provides accommodation with personal care for up to 65 older people who may be living with dementia and/or have a physical disability. The service is divided into two adjoining units. One for people with more complex needs called The Manor (with 37 beds) and another for people with lower care needs called The Lodge (with 28 beds). On the day of the inspection there were 61 people living at the service, 27 people at The Lodge and 34 people at The Manor.

We carried out this unannounced inspection of Ashleigh Manor Residential Care Home on 27 and 28 September 2017. At this comprehensive inspection we checked to see if the service had made the required improvements identified at the inspection in November 2016.

There was not a registered manager in post as the previous registered manager had left working for the service in August 2017. Another manager was appointed soon after who was responsible for the day-to-day running of the service. This manager told us they intended to apply to become the new 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 and associated Regulations about how the service is run.

In November 2016 we found aspects of the service provided to people that were not safe. People’s medicines were not managed safely. Risks were not being assessed for people in relation to the risk of choking, the risk of smoking and how to manage risks associated with specific health conditions. Staff were carrying out some care and treatment without the qualifications and competence to do so. Equipment used for staff to carry out health checks and first aid were not properly maintained or used correctly. There was a lack of robust procedures in relation to the prevention and control of the spread of infection.

At this inspection we found improvements had been made. Risk assessments had been updated and individual assessments were in place which identified any risks relevant to the person and gave instructions for staff to help manage the risks. Equipment used for staff to carry out health checks and first aid had been serviced and there was a system in place for regular servicing. Team leaders had been trained to carry out some routine health checks and the service had ceased carrying out some other checks. Revised infection control procedures had been implemented and a head of infection control and housekeeping had been appointed. The service was visibly clean throughout and there were suitable levels of PPE (Personal Protective Equipment).

A review of medicines procedures and an update of staff training meant people were receiving their medicines in a mostly safe way. There were gaps in records for when staff applied creams. Some people were prescribed to have medicines administered by an external health professional every three months. There were no records made to show when the next administrations were due and we found that one person was overdue their medicine.

In November 2016 while we found there were sufficient staff on duty, based on the provider’s dependency assessment, staff were not always deployed effectively. There were gaps in the information communicated to staff when they started a shift and staff were not always clear about their responsibilities. This meant staff were not being used effectively and flexibly to meet people’s needs. At this inspection we found improvements had been made to the structure of how staff were deployed. Roles and responsibilities had been defined and communicated to staff. Handovers had improved and staff told us they felt more confident about carrying out their roles. However, the number of staff on duty regularly fell below the level assessed by the provider as being needed to meet people’s need

The inspection took place on the 1, 2 and 3 November 2016 and was unannounced. We completed a comprehensive inspection on the 30 June 2015 and rated the service as Good. Prior to this inspection we were contacted by the local authority to be advised there were a number of safeguarding concerns being investigated by social workers. These covered a wide range of issues including how the service was addressing risks to people in respect of falls, malnutrition and their skin. Concerns were also raised regarding staffing, training, the cleanliness of the service and how people’s individual needs were being met. CQC had also received information about errors in medicine administration since the last inspection. This included giving medicines to the wrong person. We reviewed the concerns raised during the inspection and found a number of concerns which reflected the same issues we had been told about prior to our visit.

Ashleigh Manor Care Centre (known locally as “Ashleigh Manor”) is registered to provide care to up to 65 older people who may be living with dementia and/or have a physical disability. There were 57 people living at the service when we visited. Ashleigh Manor had two sides with separate entrances to the one service. There was “The Manor” where people with more complex needs lived. Then there was “The Lodge” where people who had lower needs resided.

A registered manager is registered with the CQC but is no longer 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. A new manager had been in post since 19 September 2016. They were in the process of registering with us.

Throughout the inspection we identified that systems were not always in place to ensure the service was safe, effective, caring, responsive and well-led. This affected several aspects of people’s lives while living at the service. For example, staff were making decisions about people’s care and treatment without communicating this to senior management. Staff were also not always recording this information so it was available for other staff to meet people’s needs in a consistent way. Health professionals told us messages were not always passed on or they could not speak with the staff member who held the information they needed. This impacted on their ability to assess people’s needs fully.

People’s care and treatment was not always planned to keep them safe or meet their needs in a personalised way. From admission to living short or long term at the service, there were gaps in people’s records. Information about people from the referring agency or discussions with people were not always being acted on. Risk assessments were not always completed which reflected people’s needs. For example, the risk of choking or from specific health needs, such as diabetes, was not being assessed. Information which was essential to staff meeting their needs and keep them safe was not being collated. People were not having their end of life wishes and needs assessed.

Staff recording of aspects of people’s care was variable and incomplete. For example, recording of how much people were eating and drinking when there were concerns had gaps in it. Whether staff were applying prescribed creams was not being recorded. Daily records of people’s days and significant events were inconsistent or had not been recorded at all. This meant it was unclear whether people were having their needs met.

People were not being assessed in line with the Mental Capacity Act 2005. Some people had generalised assessments in place when it was felt they lacked the capacity to consent to their care. Decisions were being made about people’s care without ensuring there was a mental capacity assessment in pla

This inspection was to follow up on some concerns about the way medicines were managed after our previous inspection in October 2013. We found that these concerns have been addressed, and that there have been improvements to the way medicines were handled.

On the day of our visit we were told that there were 55 people living at Ashleigh Manor. We spoke to ten people living at the home and one relative, spent time observing the care people were receiving, spoke to 14 members of staff, which included the unregistered manager and looked at four people’s care files in detail.

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.

We looked at care records for four people. We spoke to staff about the care given, looked at records relating to them, met with them and observed staff working with them.

We saw that people's care records described their needs and how those needs were met. This meant that people’s care and welfare needs were being met.

We saw that medication was administered by suitably trained staff. People were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to administer and record medication.

We saw that Ashleigh Manor Residential Home held all records securely to protect people’s confidentiality.

We met and spoke with most of the 51 people living in Ashleigh manor. The home is divided into two areas, The Lodge and The Manor. We spoke with one visitor and talked with the staff on duty and also checked the provider's records.

People living in Ashleigh Manor received care or treatment staff attempted to obtain consent when possible and the staff acted in accordance with their wishes.

We saw that people were left for long periods without any interaction.

Staff we spoke with were clear about the actions they would take should they have any concerns about people's care and welfare.

We looked at care records for six people living in Ashleigh Manor. We spoke with staff about the care given, looked at records relating to them, met with them and observed staff working with them.

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

Care plans did not always reflect people’s health and social care needs. People were not always updated about their care needs. This meant that people’s care and welfare needs may not have been met. We saw that people's mental capacity was assessed to determine whether they were able to make particular decisions about their lives.

People who lived in the home were not always informed about changes in the management of the home

We spoke with most of the staff working during our visit. Some of the staff had worked at the home for some time and one said, “I love my job”.

We visited Ashleigh Manor to look at areas of concern received. These concerns related to people’s nutritional needs not being met and some staff not adequately trained.

We spoke to sixteen people who used the service, eleven staff members and one visiting relative. We also observed staff interaction with people as some were unable to communicate with us. We talked with the staff and the recently appointed registered manager.

We looked at the care records of four people who used services and this involved looking at the eating and drinking sections of the care plans, with a follow up look at weight charts, food and fluid charts and monitoring of all these aspects for people’s wellbeing.

We saw and heard staff speak to people in a way that demonstrated a good understanding of people’s choices and preferences. We spoke to staff about the meals provided, looked at records related to individual’s eating and nutritional needs and met with individuals and observed staff working with them, particularly at a main meal time.

There were enough staff on duty to meet people's needs with additional staff available when required. Staff had received training to enable them to carry out their roles competently and ongoing training was available.

We made an unannounced visit to Ashleigh Manor Residential Home due to the service notifying us of a serious accident there. We looked at the care and welfare of people who used the service.

During our visit we spoke with five people who used the service, two relatives and the registered manager. We spent time observing people and how staff interacted and supported them.

A relative of a person using the service told us "people here are lovely". A person using the service told us that they "were surrounded by such good friends". They told us that they had "made the right choice in coming here".

We looked around the home, and saw nothing that could pose a danger to people living there.

We examined care files belonging to three people who lived in Ashleigh Manor Residential Home and found that risk assessments were in place. These included mobility assessments. Where accidents had happened, for example a fall, the records we saw had been updated to reflect the accident and further controls were implemented to reduce the risk.

You can see our judgement on the front page of this report.

At the time of our visit there were compliance actions open from a previous inspection. The provider had provided a plan to the commission to address these actions. The timescale for completing the actions had not yet past at the time of the visit. We saw the provider had been making progress with the actions.

We made an unannounced visit to the home on 28 June 2012 and 7 August 2012 as part of this inspection. There were 56 people living there when we first visited. We spoke with 14 people to ask their views of the service, and with the visiting relatives of two other people. We met others who lived at the home who were unable to tell us about their life at the home because of their physical or mental frailty. We observed some of the support people received from staff, to get a better understanding of their experiences, especially where they were unable to speak with us. We also spoke with two visiting health professionals, 10 care and ancillary staff, the registered manager, the deputy manager and administrative staff.

Some people we spoke with felt they were kept sufficiently informed about events at the home with one saying they could do as they wanted. People's privacy and independence were supported, such as through provision of simple bedroom door locks and signage around the home, although we observed that people’s dignity was not always protected.

Comments from people who lived at the home included "I am happy, they look after us well.” Another commented “It would be better if we had activities...” Regarding the food provided, one person told us "We get jolly good food, you get a choice, they ask, do you want so and so?", while another remarked on the length of time between tea and breakfast: "You don’t get supper – we used to get crackers and cheese. It doesn’t happen now. We could do with a snack..." The registered manager told us she would look into this as she expected people would have been offered supper, with snacks available at other times.

People had not been involved in the same ways regarding decisions about their care. Some had detailed person-centred care plans written with input from the individual concerned or their advocate, whilst others did not. We found the delivery of care did not always meet people's needs.

Comments from people included that staff were “not very present...though lovely people," “Not always enough staff”, “Very good but busy”, and, “If you press the buzzer they come.” We saw staff took time to stop and engage in a friendly or kindly way with people as they passed them. People told us they felt safe with staff and that they could raise concerns if they had them.

When asked about the cleanliness of the home, one person commented “It’s mostly clean. I have to occasionally ask for a vacuum.” Another person told us their room was kept clean, although there was a lack of evidence to show cleaning was carried out regularly in all rooms. We found that the home's systems for assessing and monitoring the service were not fully effective. The service responded to concerns raised on our first visit and raised by other visiting professionals, rather than being proactive and addressing such issues before others raised them.

We visited the home unannounced as it had been identified that a significant number of deaths had occurred since September 2011.

We looked at the care records for some of the people who had died and we spoke with the care manager for the home and with one visiting professional. We saw that four people had been on the Liverpool Care Pathway (LCP) when they died. The LCP is a system which allows people to be cared for with dignity at the end of their lives.

Because of the nature and subject of our concerns we did not speak with any one living at the home during this visit.

Care and treatment was planned and delivered in a way that ensured people's safety and welfare. No concerns were noted relating to the number of deaths.

Recordings for people who received Controlled Drugs who were not on the LCP were correct.

The provider might find it useful to note that discussions with District Nurses may lead to a better system for obtaining and recording Controlled Drug medications to be used with the Liverpool Care Pathway.

On our visits to the home we spoke with the people living there about the ways in which people are involved in the services they receive.

We saw staff promoting people’s independence with regard to their mobility, eating and drinking. We also saw and heard staff treating people with respect and any personal care that was offered was done so in a discreet manner.

The provider told us that staff had not received any training in relation to the Mental Capacity Act (MCA). This Act is in place to ensure everyone has the right to make their own decisions unless it is proven it is not in their best interests to do so. It must be assumed that people have the right to make decisions – even bad ones – unless there is evidence that they do not have capacity to do so.

It was clear that the provider and staff had worked hard to improve the care plans used and we spoke to the member of staff who has been mostly responsible for the new care plans. Staff were aware of people’s care plans and were able to tell us about the needs of the people they care for. They told us that they would be made aware of any changes to people’s care plans at a handover before they started their shift. We saw people receiving care from staff, and this showed us that staff understood people’s needs and were quick to react to changes.

We saw some occasions when people’s dignity was not maintained. For example, we saw several people wearing stained clothing and some people’s hair had not been brushed. We also had concerns over the particular behaviour of person. This was discussed with the provider who has agreed to look at ways of managing the person’s behaviour in a non restrictive way which will also maintain their dignity. On our second visit we saw that new clothing had been purchased and the person’s dignity was being maintained.

At lunchtime we joined people for lunch, which we found to be of plentiful and of good quality. People that we spoke with during lunch told us that the food was ‘excellent’, that there was always plenty of choice and that they could always have an omelette if they didn’t want what was on the menu.

We looked at the communal areas of the home and some bedrooms. Areas that we saw were generally clean and tidy and there were no unpleasant odours. However, we saw some people eating their breakfast in rooms that were very messy. There are several distinct areas of the home each with their own communal spaces. The newer areas of the home have under floor central heating and were generally better decorated than the older parts of the home.

We saw staff helping people with their mobility and helping make others comfortable. They were using suitable equipment safely, including sliding sheets and belts.

People told us that the staff at the home were “very good” people who supported them well.

Recruitment procedures at Ashleigh Manor are robust and ensure that people who may be unsuitable to work with vulnerable people are not employed at the home.

Regular meetings are held for people who live at the home and for their representatives. People who were able to speak with us told us that they knew how to raise concerns and would feel comfortable to do so if they were not happy about anything.

We saw how records about the care of people who live in the home were being maintained and kept. We saw that these records were being well maintained by the staff team. Any information about an individual had been regularly reviewed to ensure that it was correct and still meeting the individual's needs.

The Inspection took place on 7 and 17 April 2015 and was unannounced. This was Ashleigh Manor Care Centre’s first inspection since registering as nursing care. The service is divided into two areas. The “Manor” is currently home to people living with dementia and the “Lodge” is for people requiring residential care.

Ashleigh Manor Care Centre provides care and accommodation for up to 65 older people, some of whom are living with dementia, have a physical disability or require nursing care. On the day of the inspection 60 people lived at the home. There were 28 people in ‘The Lodge’ and 32 people in ‘Ashleigh Manor.’

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (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.

We observed during our inspection people and staff were relaxed. There was a friendly and calm atmosphere. We observed people and staff chatting and enjoying each other’s company. Comments included; “Staff look after me well.” People, who were able to tell us, said they were happy living there.

People had their privacy and dignity maintained. We observed staff supporting people and showing kindness and compassion throughout our visit.

People, relatives and healthcare professionals were very happy with the care provided to people and said the staff were knowledgeable and competent to meet people’s needs. People were encouraged and supported to make decisions and choices whenever possible in their day to day lives.

People were protected by safe recruitment procedures. There were sufficient staff to meet people’s needs and staff received an induction programme. Staff had completed appropriate training and had the right skills to meet people’s needs.

The registered manager had sought out and acted upon advice where they thought people’s freedom was being restricted. This helped to ensure people’s rights were protected. Applications were made to help safeguard people and respect their human rights. Staff had undertaken safeguarding training, they displayed a good knowledge on how to report concerns and were able to describe the action they would take to protect people against harm. Staff were confident any incidents or allegations would be fully investigated. People who were able to told us they felt safe.

People had access to healthcare professionals to make sure they received appropriate care and treatment to meet their health care needs such as occupational therapists and GPs. Staff acted on the information given to them by professionals to ensure people received the care they needed to remain safe.

People’s medicines were managed safely. Medicines were managed, stored, given to people as prescribed and disposed of safely. Staff were appropriately trained and confirmed they understood the importance of safe administration and management of medicines.

People’s risks were considered, managed and reviewed to keep people safe. Where possible, people had choice and control over their lives and were supported to engage in activities within the home and outside where possible. Records were updated to reflect people’s changing needs. People and their families were involved in the planning of their care.

People were supported to maintain a healthy, balanced diet. People told us they enjoyed their meals and did not feel rushed. One person said, “All the food is good…and I’m fussy but they always find something for me.”

People’s care records were comprehensive and detailed people’s preferences. People’s communication methods and preferences were taken into account and respected by staff. They contained detailed information about how people wished to be supported. Records were regularly updated to reflect people’s changing needs. People and their families were involved in the planning of their care.

People, staff and visiting healthcare professionals confirmed the management of the service was supportive and approachable. Staff were happy in their role and spoke positively about their jobs.

People’s opinions were sought formally and informally. There were quality assurance systems in place. Audits were carried out to help ensure people were safe, for example environmental audits were completed. Accidents and safeguarding concerns were investigated and, where there were areas for improvement, these were shared for learning.