The inspection took place on 16 and 17 July 2018. The inspection was unannounced.

Ashley House is a ‘care home’. People in care homes receive accommodation and nursing and 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. Ashley House provides accommodation and support for up to 17 older people living with dementia. There were 15 people living at the service at the time of our inspection.

There was a registered manager in post who was present on both days of inspection. 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.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the responsive and well led domains to at least good. Our last inspection on 18 May 2017 found one breach of our regulations and an overall rating of requires improvement was given at that inspection. This was because records were not being maintained to provide an accurate contemporaneous record. Information in people’s care plans detailing their care and support needs was not always current to inform and guide staff. Audits of the service were undertaken but were not effective in highlighting shortfalls and were an area for improvement. The provider sent us an action plan after this inspection telling us how they would improve and when this work would be done.

Improvements had not been embedded or sustained and the original breach has subsequently not been met. Person centred care plans were still not always reflective of current care and support needs. We found that further shortfalls in relation to the governance of the service had occurred, some risks had not been identified and addressed to keep people safe and there were several areas for improvement. The previous ratings for the key questions safe and effective had not been sustained. The overall rating for the service remains at requires improvement. This is the third consecutive time the service has been rated requires improvement.

We found that some risks were not identified and therefore measures not implemented to protect people from harm. We observed a missing window restrictor on a first floor window, loose stair carpet and unsafe storage of oxygen. These shortfalls could place people at risk of harm. The system of audits and checks in place to monitor service quality did not always identify the shortfalls as intended and other shortfalls were not considered at all. For example, there was no system for monitoring air mattress settings to protect people’s skin integrity and no clear responsibility for cleaning the medicine room to maintain good infection control. Safety recommendations from equipment servicing was not included in the maintenance plan. Recommendations from pharmacy audits were not actioned. This meant there was a risk that some shortfalls were being overlooked and could impact on the operation of equipment or pose a risk to people or staff. The provider had not ensured that staff were working to the most up to date policies.

Not all aspects of cleanliness and infection control were monitored. An absence of a robust cleaning and monitoring schedule meant some areas of the service were not sufficiently clean. Equipment was serviced at regular intervals to ensure it remained in working order.

A complaints procedure was displayed for people to use if they wished. However, accessible information about the service including the complaints procedure was not in formats suited to the needs of those with dementia or cognitive problems and is an area for improvement. People and relatives told us that they

This inspection took place on 18 May 2017 and was unannounced. The previous inspection was carried out in March 2016 and concerns relating to the management of medicines, the assessment and management of risk, potential environmental hazards, staff training and quality management were identified. At that time we asked the provider to send us an action plan about the changes they would make to improve the service. At this inspection we found that actions had been taken to implement these improvements. However, some areas required further improvements.

Ashley House is registered to provide personal care and accommodation for up to 17 people. There were 16 people using the service during our inspection; who were living with a range of health and support needs. Many people were living with different types and stages of dementia. Ashley House is a detached house situated in a residential area in Folkestone, with access to the town centre. There were 16 bedrooms, one being able to offer double occupancy. People’s bedrooms were provided over three floors, with a passenger lift in-between. There were sitting and dining rooms on the ground floor and an enclosed garden to the rear.

The service had a registered manager, who was present throughout the inspection. 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.

The care and support needs of each person were different, and each person’s care plan was personal to them. People had care plans, risk assessments and guidance in place to help staff to support them in an individual way. However, information and guidance contained within care records was not always the most recent.

A number of audits and checks were carried out each month by the registered manager or area manager, but they had not been effective in identifying the shortfalls in current information within care plans highlighted during our inspection.

There were enough staff on duty and they had received relevant training and supervision to help them carry out their roles effectively. Staff were observed putting their training into practice in a safe way. There was no use of a formal dependency tool to enable to registered manager to assure themselves that staffing levels remained adequate. Recruitment files contained all the required information about staff.

Staff knew how to keep people safe from abuse and neglect and the manager referred any incidents to the local safeguarding authority as appropriate. Incidents and accidents had been properly recorded and preventative actions taken. Fire safety had been addressed through training, drills and alarm testing. Maintenance had been carried out promptly when repairs were needed.

Medicines were managed safely. People received their medicines safely and when they needed them. People were supported to maintain good health and attended appointments and check-ups. Health needs were kept under review and appropriate referrals were made when required.

Staff encouraged people to be involved and feel included. There were positive and caring interactions between the staff and people and people were comfortable and at ease with the staff. People's privacy and dignity was respected.

Staff treated people with kindness, compassion and respect. Staff took time to speak with the people they were supporting. We saw many positive interactions and people enjoyed talking to the staff. The staff on duty knew the people they were supporting and the choices they had made about their care and their lives.

Activities were offered to people; with a range of one to one and group activities to meet individual needs and preferences.

Complaints had been properly documented, and recorded whether complainants were satisfied

The inspection took place on 16 March 2016 and was unannounced. At the previous inspection on 9 July 2014, we found there were no breaches of legal requirements.

Ashley House provides accommodation with personal care for up to 17 older people living with dementia. There are 15 single and one double room available. There were 15 people living at the service at the time of inspection and everyone was living in a single room. The accommodation is over two floors and bedrooms can be accessed by a passenger lift. There is a communal lounge at the back of the home with access to a secure garden. There is also a separate dining room where most people eat their meals.

The service has a registered manager who was available and supported us during the inspection. 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.

Medicines controlled under the Misuse of Drugs Act 1971 to prevent them from being misused and causing harm, were not stored securely at the service. There were no protocols in place for people who were prescribed their medicines to be given ‘as required’. There was no guidance in place for staff to follow to maintain the health of people with diabetes.

The hall and stair carpet was worn, had a number of small holes and a patch by the dining room door, which posed a tripping hazard. The provider was aware of the hazard, but had taken no action to address it to make the environment safe.

Each person had an individual plan in place detailing how to evacuate them in the event of a fire. However, the equipment needed to evacuate one person safely, was not available at the service.

Around half the staff team had not received training in areas essential to their role, including safeguarding, health and safety, fire prevention, infection control, moving and handling people safely and The Mental Capacity Act 2005 (MCA). The service specialised in supporting people living with dementia but care staff had only received basic training in this area and had received no training in how to effectively support people with behaviours that may challenge themselves or others. There was no plan in place which identified when these training gaps would be met.

There was not an effective quality assurance process in place and the provider did not respond to shortfalls identified in the service in a timely manner.

People had their health needs assessed and monitored and professional advice was sought as appropriate. People were offered a choice at mealtimes, and where appropriate support was provided and people were not rushed.

CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards. The registered manager had consulted the local authority with regards to making DoLS applications, so people were not deprived of their liberty unnecessarily.

Staff said there was good communication in the staff team, that they felt well supported and received regular formal supervision with the registered manager.

Checks were carried out on all staff to ensure that they were fit and suitable for their role. Staffing levels ensured that staff were available to meet people’s needs. Staff knew how to follow the home’s safeguarding policy in order to help people keep safe.

The home was clean and staff knew what action to take to minimise the spread of any infection.

People, visitors and professionals gave positive feedback about the compassionate and caring nature of the staff team. Staff were kind and caring and communicated with people appropriately using touch. Staff valued people, showed concern for their well-being and involved them in decisions about their care.

People’s care, treatment and support needs were assessed be

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us due to communication difficulties:-

We considered our inspection findings to answer questions we always ask:

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with relatives and speaking with staff.

Is the service safe?

People were treated with dignity and respect by the staff. They knew how to communicate with individual people who lived in the home and did so in a way that valued their contributions. One relative told us, “The staff are lovely. It is like a big family”. Another relative told us, “Mum is well looked after. They let us know what is going on. I do not worry when I leave Mum”.

There were systems in place to ensure that the environment was clean and hygienic. Staff understood their roles and responsibilities in ensuring that the home was clean and had received training in how to minimise any infection.

Checks had been carried out for staff before they started work at the home, to ensure that they were suitable for their roles.

Systems were in place to monitor accidents and incidents. This reduced the risks to people and helped the service to continually improve.

Is the service effective?

Relatives were very positive about the care that was delivered and said that their relatives’ needs were met.

People’s health and care needs were assessed with them, and they and/or their relatives were involved in writing their plans of care. This included important information about people’s likes, dislikes and past histories, so that staff could communicate with people more easily.

Staff had a good understanding of people’s care and support needs and they knew them well. We observed staff communicating with people about things that were important to them.

Is the service caring?

People were supported by kind and attentive staff. For example, we saw staff sitting down beside people when talking with them and supporting them to eat and drink. Staff showed patience and gave encouragement when supporting people. When supporting people to mobilise, they explained and involved the person in every step of the process.

People were able to do things at their own pace and were not rushed. We saw that there was a relaxed atmosphere at lunchtime and that meal times were staggered so that people could be provided with the individual support that they required

People’s preferences, interests and diverse needs were recorded and care and support was provided in accordance with their wishes.

People using the service, their relatives, staff and other professionals involved in the service completed an annual satisfaction survey. Any shortfalls had been identified and action had been taken to address them.

When speaking with staff it was clear that they genuinely cared for the people they supported.

Is the service responsive?

People’s needs had been assessed in detail before they moved into the home.

People had a designated key worker and protocols were in place setting out their roles and responsibilities

People had access to activities that were important to them, in the home. An activities coordinator was employed two afternoons a week. Staff said that they had time to sit and talk to people and showed us some of the activities that they engaged people in such as picture bingo.

People had been supported to maintain relationships with their friends and relatives.

Relatives said that they knew how to make a complaint if they were unhappy, but said that they had not needed to.

Is the service well led?

The home manager had worked at the home for many years, was registered with the Care Quality Commission and had achieved a national qualification to manage a social care service.

Staff had a good understanding of the ethos of the home. They told us that they were clear about their roles and responsibilities, felt well supported, and that there was good communication in the home. All these things helped them to provide the appropriate support for people who lived in the home.

The service had an effective quality assurance system in place which consisted of internal audits and external audits by the provider.

Relatives, staff, people who used the service and professionals completed an annual customer satisfaction survey. The results were analysed by the provider so that any shortfalls could be addressed.

At the time of our inspection, there were 14 people who lived at the home. We spoke with four people who used the service, two visiting relatives and two professional visitors.

We spoke to people and their relatives, who told us that they were happy with the care and support the home provided. One person told us “staff are very good; they work hard and communicate well with people”. A relative told us “I wouldn’t hesitate to recommend the home to other people”.

We found that care plans were individualised and contained people's choices and preferences and that people’s health care needs were met. A relative told us “the staff respond well to people’s needs”.

We found that the home had arrangements in place to protect people from the risk of abuse and people told us that they felt safe.

We found that the home had appropriate arrangements in place to manage people’s medicines and staff had received training to administer medicines safely.

We found that staff were supported by the provider to effectively meet the needs of people who lived in the home. One person told us “they are well trained to look after individuals”. A member of staff said “they are the best manager I’ve ever had”.

At the time of inspection 14 people lived at the service. People told us “I like everything” and “I live like a queen”. Relatives told us that the staff kept them updated on their relative’s needs. A relative told us they were able to go abroad for the first time in years because their relative was so well cared for. Another relative told us “The staff are very caring and friendly”.

A healthcare professional linked to the service told us “It is one of the best homes I have been in, the staff are well trained and caring."

We saw that there were systems in place to monitor people’s capacity to give consent and ensure decisions were made in their best interests.

We saw that people had their needs assessed, met and reviewed at the service. However, we noted an example where a lack of guidance for staff around responding to a person’s behaviour meant a staff member’s response caused the person some distress. The manager amended the guidance during the inspection.

People told us that the staff were able to meet their needs and there were enough staff on duty to meet their needs effectively.

We saw that the environment was homely and regular health and safety checks were undertaken of the service. There was a system in place to maintain the service including redecorating areas that had become worn.

There was a complaints system in place and information for staff, relatives and people around how to make a complaint. No complaints had been made.

People told us that they had the care and support they needed to remain well and healthy. Everyone we spoke to said good things about the staff like ‘They are kind’ and ‘The staff are excellent’. People said that they thought that there were enough staff on duty.

People said they liked living at the home and they were involved in decisions about their care and support.

They told us that the food was good and that they were happy with their bedrooms.

People told us that they were satisfied and happy with the service. They said that the manager checked to make sure they were happy with the home.

They told us that the staff treated them with respect, listened to them and supported them to raise any concerns they had.

The people that use the service at Ashley House had 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 allowed us to spend time watching what was going on in the service and helped us to record how people spent their time, the type of support they got and whether they had positive experiences.

Overall we found people had positive experiences. In the morning we were in the lounge at the home. We saw that people were occupied with a variety of activities. Staff were attentive, responding positively when they were approached and gave lots of encouragement to people. The staff supporting people knew what support they needed and they respected their wishes if they wanted to manage on their own.