The last inspection of this service took place on 05 January 2016. The service was awarded a rating of 'Requires Improvement.' The service was found to be in breach of the regulations relating to need for consent, safe care and treatment and safeguarding service users from abuse and improper treatment. We were provided with an action plan following the inspection carried out in January 2016.

Ashleigh Rest Home accommodates older people who are living with dementia. The home had 11 single bedrooms, four of which had en-suite facilities.

The service is registered to provide accommodation for persons who require nursing or personal care. There is 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.

People who lived at Ashleigh Rest Home told us they felt safe and supported by staff and the management team.

During our last inspection, we found issues with the reporting of safeguarding incidents. We found not all safeguarding incidents had been appropriately reported to the relevant authorities. We looked at how reporting of safeguarding incidents were being managed during this inspection. We found people were protected from the risk of abuse because staff understood how to identify and report it.

During our last inspection, we found evidence risk assessments were not always updated following a change in needs. We looked at how risks to people were being managed during this inspection. We found people were protected from risks associated with their care because the registered manager had completed risk assessments, which provided updated guidance for staff in order to keep people safe.

During our last inspection we found no additional checks were documented following an accident. This put people at risk of harm. In addition there was no evidence available to show that accident and incident records had been reviewed, in order to identify and analyse any trends or patterns. We looked at how accidents and incidents were being managed during this inspection. There was a central record for accident and incidents to monitor for trends and patterns and the management had oversight of these.

During our last inspection, we made a recommendation that the provider follows best practice guidelines around infection prevention and control in care homes. We looked at infection control processes at this inspection and found improvements had been made.

During our last inspection, we made a recommendation around keeping Personal Emergency Evacuation Plan [PEEPs] up to date. We looked at PEEPs during this inspection and found people had up to date PEEPs in their files to aid safe evacuation.

During the last inspection, we found in some care files, consent forms had not been completed. We also found some examples where consent had been provided by people's family members, but there was no confirmation that people who had provided consent had legal authority to do so.

We found mental capacity had been considered and written consent to various aspects of care and treatment was observed on people's files.

We checked whether the service was working within the principles of the MCA, and whether any conditions on authorisations to deprive a person of their liberty were being met. We viewed records for two people documenting evidence conditions for DoLs authorisations were being followed.

During our last inspection visit, we made a recommendation around reviewing care files and the systems in place to ensure these were kept up to date. At this inspection we saw care records were written in a person centred way. Staff took note of the records and provided person centred care.

During our last inspection at the service, we found concerns

We inspected this service on 5 January 2016 The inspection was unannounced. The service was last inspected on 29 October 2013, when we found the provider was compliant with the regulations we assessed at that time.

Ashleigh Residential Home accommodates older people who are living with dementia. The home has 11 single bedrooms, four of which had en-suite facilities. The home is situated in a quiet residential area and has a pleasant garden. Local amenities including bus stops, a church and shops are situated nearby.

The service is registered to provide accommodation for persons who require nursing or personal care. There is 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.

We found that the principles of the Mental Capacity Act (MCA) 2005 were not embedded in practice. Records showed that consent had been obtained in some areas. However, the service had not implemented a system to adequately assess people’s mental capacity in relation to the decision making process. Therefore, some people may have signed consent forms without fully understanding what they were signing.

We looked at how the service protected people from avoidable harm and known risk to individuals. Risk assessments were included in people’s care files and actions were documented clearly for staff to follow. However risk assessments were not always updated following a change in people’s needs.

We found that the service did not always follow safeguarding reporting systems, as outlined in the home’s policies and procedures. Accidents were recorded in the accident book. However, there was no evidence available to show that this information had been reviewed, in order to identify and analyse any trends or patterns.

There was effective communication between all staff members, including the managers. There was an established staff team, who knew about people’s individual care needs and who were passionate about their jobs and caring for others.

We found that written policies in relation to the recruitment of new staff were in place at the home. Records we saw demonstrated that safe practices had been adopted to ensure that staff employed were suitable to work with this vulnerable client group.

We found that the home was clean and tidy throughout. The provider had a policy with regards to infection control and records demonstrated that staff had been provided with training in this area. However, we found that best practices for infection control were not always being followed. We have made a recommendation regarding this.

We found that Personal Emergency Evacuation Plan [PEEPs] were generic and did not contain personal information to show how each individual could be best assisted to evacuate the premises, should the need arise. We have made a recommendation with regards to this.

There were some effective quality assurance systems in place that monitored care. However these systems did not always pick up on failings around valid consent and incident failings highlighted in this report. We have made a recommendation with regards to this.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 relating to consent, safe care and treatment and safeguarding people from abuse.

You can see what action we have asked the provider to take at the back of this report.