This inspection took place on the 30 and 31 October 2018 and was unannounced.

Ashley House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

The home is registered to accommodate up to 18 people, with 17 people living at Ashley House at the time of our inspection. There are three shared rooms and 13 single rooms with people sharing bathrooms. The home is an older building with lift access to the first floor. There are two lounges and a dining room on the ground floor and a garden accessible by a ramp to the rear.

Ashley house has a registered manager who had been in post since 2014. 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 September 2017 we found breaches in three Regulations because care plans and risk assessments did not include all the details of people’s support needs, activities were not available for people to take part in, there were hazards around the building, medicines were not always managed safely and the quality assurance system was not sufficiently robust.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve all the five key questions of safe, effective, caring, responsive and well led to at least good.

At this inspection we found there had been some improvements made. Medicines were administered as prescribed, although guidance for when to administer medicines not taken regularly had not been written for people who had recently moved to the home. Hazards around the building had been addressed and a programme of refurbishment was in place, with some improvements having been completed in 2018 and more planned into 2019. More activities were being organised.

However, there were continued breaches in two regulations. There was an inconsistent use of pre-admission assessments and care plans for people moving to the home were not completed in a timely manner. Care plans were personalised, included all of people’s support needs and were regularly reviewed. More detail was required in some care plans to provide clear guidance for staff in how to meet people’s needs.

Quality assurance systems were not robust and audits had not been completed regularly. Formal checks of the call bell system, water temperatures, window restrictors and wheelchairs were not made. The providers regularly visited the home but did not make any formal checks to assure themselves of the quality of the service or to identify any improvements that may be required.

A new breach was found as the home was not following the principles of the Mental Capacity Act (2005). People assessed as not having the capacity to consent had signed consent forms for their care and support. Decision specific capacity assessments and best interest decisions were not in place.

There was a further breach as issues identified in a legionella risk assessment had not been acted upon and emergency lighting bulbs had not been replaced in a timely manner.

The registered manager had had little managerial support since March 2018 when the deputy manager had left the service. New senior care workers had recently been appointed and a new deputy manager was due to start work the week after our inspection. This should provide additional support for the registered manager, with some tasks being delegated to the new management team.

Incidents and accidents were recorded and reviewed by the registered manager to look if there were any patterns. We have made a recom

The service was last inspected in December 2014 when it was found to be meeting all the regulatory requirements, and the service was rated ‘Good’ overall.

Ashley House Residential Home (known as 'Ashley House' by the people who live and work there) is registered to provide accommodation and personal care for up to 18 people, some of whom are living with dementia, there were 17 people living at the home at the time of our inspection. The home is situated on the main road close to local amenities and public transport links into Manchester city centre, Didsbury and Chorlton. The home is a large detached property set in its own grounds. Car parking is available on the road. There is a lounge and a separate dining room on the ground floor. There is a passenger lift in place along with facilities for cooking, dining, personal care, relaxing and leisure.

During this inspection we found six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, relating to management of medicines, risk assessments, person centred care, meeting people's social needs and quality assurance. You can see what action we told the registered provider to take at the back of the full version of the report.

There was 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 people were not always protected from risks associated with their care because risk assessments were not always robust enough to provide guidance and direction to staff about how to keep people safe. People did not always have sufficient detail in their care plans to provide guidance and direction to staff about how to meet their needs.

People's medicines were not managed safely. For example, we observed one care worker not safely observing the person taking their medicines they had just administered. We found the storage of controlled drugs did not meet the requirements of the Misuse of Drugs Act 1971. We found there were no plans, or 'when required' (PRN) protocols in place to inform staff when and how they should administer people medicines that were not required routinely.

During our tour of the building we noted several potential safety hazards. We found in the first floor bathroom had two radiator covers stored behind the bath tub. Both radiator covers had sharp edges and we requested that they were removed immediately. We found items of clothing and an inflatable mattress were being stored under the stairwell, this posed as a potential fire risk.

Overall people and relatives spoken with were positive and complimentary about the service they received at the home. People told us that they felt safe and were cared for.

During this inspection we found there were enough staff available to meet the needs of people living at the home. However, staff didn’t have time to provide social interaction with people and we noted the care hours during the weekend were reduced by one 8am to 2pm shift. We have made a recommendation the home considers introducing a dependency tool which will provide further clarification on whether the current staffing levels are adequate.

Activities on offer to people were limited. We received a negative response from people in relation to activities. The range of activities available was not always appropriate or stimulating for people. This meant people were not always protected from social isolation.

We saw caring interactions between staff and people. However, we observed one care worker not engaging with a person in a caring and sensitive manner which meant the person’s dignity was not respected.

The home was generally clean and tidy, although we found a malodour in communal areas. The registered manager s

We inspected Ashley House to ensure areas of concern identified at an inspection in April 2014 had been resolved. We also included other areas within our inspection as we had received some information of concern.

An inspector visited this service on 9 September to carry out an inspection. Prior to our visit we looked at all the information we hold on this service to help us to plan and focus on our five questions;

Is the service caring?

Is the service responsive?

Is the service safe?

Is the service effective?

Is the service well led?

During this inspection we spoke with one relative, three care staff and the manager of Ashley House. We also spoke with four people who lived at the home. Below is a summary of what we found.

Is the service caring?

The people we spoke with were happy with the care and support provided by Ashley House. Comments included; "I’ve no complaints about anything”, “I like it here” and “I wouldn’t want to go anywhere else.” Our observations showed people were spoken with politely and with respect.

Is the service responsive?

We saw people were encouraged to give feedback on the service in the form of surveys, and meetings took place to enable people to make comments and suggestions. We saw some audits had been put into place and some systems were still required to be introduced to identify and manage risks relating to the health, welfare and safety of people who used the service. We concluded improvements were required.

Is the service safe?

We saw some systems were in place to ensure people were safe. We saw there was a safeguarding policy in place which contained contact numbers for appropriate authorities and this was accessible to staff. We spoke with three staff who were able to describe the action they would take if they were concerned that people at Ashley House were at risk of harm or abuse.

We noted the environment required improvement to enable people to live safely. For example we saw areas of the home required repair and cleaning.

We found records required further information to enable staff to deliver safe and effective care.

We also checked if sufficient numbers of suitably skilled staff were available to meet people’s needs. On the day of the inspection we saw staff supported people promptly and the people we spoke with told us they were happy with the staffing provision at the home.

The CQC monitors the operation in care homes of the Deprivation of Liberty Safeguards (DoLS). At Ashley House there were no people for whom a DoLS authorisation had been agreed at the time of our visit and the manager told us they regularly reviewed people who used the service to ensure the appropriate processes were followed.

Is the service effective?

We saw people had access to a varied diet to enable them to meet their nutritional needs. We observed staff encouraging people to eat and drink and choice was available if people did not want the meal provided. We saw people were referred to other health professionals as required.

Is the service well led?

The service had a manager in place who has been registered with the Care Quality Commission since March 2014.

We looked at a sample of audits and saw there were some systems in place to identify when improvements were required. However we noted the audit system had not identified shortfalls in records or required maintenance to the environment.

We were informed by the manager a safeguarding incident had been referred to the local authority. The manager told us they had not referred this to the Care Quality Commission. We considered improvements were required to ensure safeguarding incidents were monitored and reviewed to identify and manage any identified risks. We considered improvements were required to ensure the service was well led.

We spoke with one relative who told us they found the manager approachable and they would speak with them if they had any concerns.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

Is the service caring?

Is the service responsive?

Is the service safe?

Is the service effective?

Is the service well led?

Below is a summary of what we found.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

Staff records contained all the information required by the Health and Social Care Act. This meant the provider could demonstrate that staff employed to work at the home were suitable and had the skills and experience needed to safely support the people accommodated.

We spoke with people who lived at the home who told us they felt safe and secure. We spoke with visitors who told us: “When I leave here I know (my relative) is in safe hands and they (staff) look after her very well.”

The staff we spoke with demonstrated an awareness of local safeguarding policies and procedures and understood the referral process. Staff were able to tell us what they would do if they had any concerns about people’s safety.

People’s needs were assessed before they moved in to the home. This was to make sure the staff were able to meet their care needs. Care plans were in place and included risk assessments.

We saw some risk assessments were not fully reflected in care plans and this posed a potential risk that people might not receive appropriate care and treatment.

The registered manager who was new in post; recognised the need to review and update people’s care plans so they provided

staff with accurate, detailed and up to date information.

There was a staffing rota to ensure adequate support was provided to people who lived at the home. The registered manager took individual care needs into account when making decisions about the numbers, qualifications, skills and experience required for carers.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Suitable policies and procedures were in place and staff had been trained to understand their responsibilities under the DoLS Codes of Practice. No applications had been made to deprive people living in the home of their liberty. Care plans and our observation of staff provided evidence of good practice in applying the least restrictive options to promote each person's autonomy.

Is the service effective?

An assessment of need was carried out before people moved into the home. This was to make sure it was the most appropriate place to meet their care needs. Care plans were being reviewed but there was no evidence that people or their relatives had been involved in the review process.

Dietary needs had been identified but they were not always reflected in the care plans. We did not see any nutritional assessments or any evidence that specialist advice had been sought for people who had special dietary needs.

The registered manager recognised the need to involve people in developing and reviewing care plans. We saw relatives had been sent a questionnaire to update contact details.

The registered manager arranged a ‘Meet and Greet’ meeting to get to know the relatives of people who lived at the home. Information leaflets about advocacy services were displayed on the notice board in the hallway.

There was a complaints procedure in place. People knew how to make a complaint if they were unhappy. The people we spoke with told us they had never had cause to complain but would discuss their concerns with the manager. People felt sure any concerns or complaints would be investigated and appropriate action taken.

Is the service caring?

We spoke with visitors who told us they were very happy with the care their relative received. Comments included: “They (staff) are definitely very caring; they look after my relative very well.” “They (staff) know what they are doing.”

We spoke with people who lived at the home who told us: “It’s a nice place I like it here they are all wonderful.” “There are new owners so we will see.” “They are all nice; we get the best of everything.” “It has changed recently.” “There is not much going on.” “They treat me very well.” “I am quite contented I can do what I want and if I need help they are here for me.”

We spent time observing interactions between the staff and people who lived at the home. We saw care was provided to a high standard. We saw staff approached people with respect in a way that maintained people’s dignity.

We have asked the provider to tell us how they are going to monitor the quality of the service they provide.

Is the service responsive?

The provider worked with other agencies such as community health and social care professionals. People were supported to attend hospital appointments and each person had access to a general practitioner.

People told us they would speak to the manager if they had any concerns and felt sure their concerns would be listened to and appropriate action taken.

The registered manager recognised the need for an effective quality monitoring system and was researching the most appropriate system for the home.

Is the service well-led?

The registered manager had not had sufficient time to carry out a full audit of the systems in place at the home.

We saw a review of care plans was underway. The registered manager told us they were planning to introduce a new format for care plans.

We spoke with staff who told us the manager had been supportive and had arranged various training courses and meetings. The staff we spoke with told us they felt the manager listened to their views and opinions.

We spoke with visitors who told us they had seen some improvements over the period of time the manager had been in post.

This inspection was carried out on 2 December and the afternoon of 3 December 2014 and was unannounced. This means we did not give the provider prior knowledge of our inspection.

Ashley House is registered to provide accommodation and personal care for up to 18 people. The home is situated on the main road close to local amenities and public transport links into Manchester city centre, Didsbury and Chorlton. The home is a large detached property set in its own grounds. Car parking is available on the road. The home has 14 single occupancy rooms and two double rooms. There is a lounge and a separate dining room on the ground floor. The first floor is accessed by a lift.

We last inspected Ashley House Residential Home in September 2014. During that inspection we identified breaches in four regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. For example we found care records did not contain accurate and up to date information relating to people’s needs and the home required maintenance and cleaning to provide a safe and suitable environment for people to live in. We also found the audit systems in place required improvement to ensure shortfalls in record keeping and the maintenance of the building were identified. The provider sent us an action plan detailing how they would ensure improvements would be made.

During this inspection we saw legal requirements had been met. Repairs and maintenance had been carried out to the environment, the home was clean and records contained accurate and person centred information to enable staff to deliver care safely and in accordance with people’s needs and preferences. We saw documentation which showed us there was an audit system in place to identify shortfalls and where shortfalls were noted, action was taken to ensure improvements were made.

The home has a manager in place who was registered with the Care Quality Commission

in March 2014. 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 saw, and were told by people that lived at Ashley House that staff were kind. We observed people being supported with respect and compassion. Staff were attentive to people’s needs and offered comfort and reassurance patiently and with kindness. We observed people engaging in organised recreational activities and saw this was a positive experience for them.

People were supported to eat sufficient amounts to meet their needs and people we spoke with told us they enjoyed the food and were offered alternatives if they did not want the meal provided. We observed people being offered choice and if people required assistance to eat their meal, this was done in a dignified manner.

The care records we viewed showed us that people’s health was monitored and referrals were made to other health professionals as required. We saw evidence that if people’s needs changed this was recorded and the staff we spoke with were knowledgeable regarding the needs and preferences of people who lived at Ashley House.

Staffing was arranged in advance to ensure there were sufficient staff to provide consistent and prompt care. Staff told us they were well supported by the manager and they engaged in staff meetings and one to one meetings to discuss their performance and any training needs. We saw documentation that confirmed this.

The environment was clean and free from clutter. We saw redecoration had taken place in some bedrooms and new furniture had been provided in communal areas and in some bedrooms. We saw documentation that showed us repairs were identified and attended to promptly and that audits were in place to check the home remained in good repair. We discussed these with the manager and the owner of the home who told us of the planned improvements they intended to make.

We saw that there were procedures in place to instruct staff in the action to take if they were concerned that someone was at risk of harm or abuse and the staff we spoke to were knowledgeable about these.