About the service: Ashley Lodge Care Home is a care home providing accommodation for up to 77 people. The service provides respite and long-term care for people requiring residential, nursing, and end of life care. At the time of the inspection there were 35 people living at the home, some of who were living with dementia. The accommodation is arranged across two self-contained buildings. Following our last inspection one of these buildings, Oakview, was closed by the Provider. There are no plans to reopen this unit at this time. The Willow and Maple units are based in the main building. Maple Unit is on the first floor and provides a secure environment for people living with dementia or other cognitive impairments.

People’s experience of using this service: A range of quality assurance checks continued to be in place. However, further work was needed to ensure that these were being fully effective at driving and sustaining improvements, and at identifying compliance with the Regulations.

Further improvements were needed to ensure that the systems and processes supporting the management of medicines were safe. Some risks associated with people's care continued to not be managed safely. There was evidence of learning from incidents and accidents but also areas where this could have been demonstrated more clearly. We have asked the provider to take some further action with regards to this.

Overall, improvements had been made to the staffing arrangements but these needed to be further embedded to ensure that people were consistently having their needs met in a timely manner.

A team of housekeeping staff were now employed seven days a week to help maintain the cleanliness of the service and they were seen to work effectively to maintain this.

Improvements had been made which ensured that people were treated with dignity and respect and staff were mindful of their privacy.

Further improvements were needed to ensure that planned care was being delivered and that staff consistently escalated concerns about people’s clinical needs.

Overall improvements had been made to ensure people's capacity to consent to their care had been appropriately assessed.

Whilst there were still some aspects of the dining experience that could improve further, overall, where people needed support to eat and drink, this was provided in a way that was dignified and respectful of the individual.

Improvements had been made to ensure that staff were adequately supported and had received an induction and ongoing training and supervision.

Staff had a good understanding of how to recognise and report potential abuse.

People were supported to access other health professionals when needed.

Staff were kind and caring and had good relationships with people. They understood people's needs and preferences and provided personalised care. There were increasing opportunities for people to engage in a range of activities.

The premises were generally suitable to people’s needs, although we have recommended that the provider continue to explore evidence based practice guidance on how environments can be designed to effectively meet the needs of people living with dementia.

People and their relatives were positive about the improvements made at the service and were confident in the registered manager's ability to continue to embed positive changes.

Rating at last inspection: Inadequate (Report published 28 August 2018).

Why we inspected: At our last inspection in May 2018, we rated the service as ‘Inadequate’ and placed them in special measures. This inspection was carried out as part of our enforcement process to check for improvements and to review the ratings. We found the provider had made improvements although there remained a breach of the Regulations in relation to risk and medicines management. There were also other areas requiring improvement noted. This meant the service was not yet consistently providing good care.

Follow up: We will

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Ashley Lodge 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.

There was not a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the home. 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 home is run. There had been six managers since the previous registered manager left in May 2017 and this had resulted in a period of instability and low staff morale. Not all staff had not felt supported during this time. The new manager had started at the home in April 2018 and is referred to throughout the report as the ‘new manager’.

There were insufficient staff deployed to meet people’s needs and keep them safe. There was a task focussed culture within the home. Risks associated with people’s health, safety and welfare had not always been identified and assessed, and guidance was not always in place to help staff to reduce those risks.

People’s plans of care did not always provide appropriate guidance for staff and people were not always supported in line with their assessed needs. Most staff were kind and caring although people were not always treated with dignity and respect and were not always encouraged to maintain their independence and choice.

People’s medicines were not managed safely. Staff administering medicines were constantly interrupted which increased the length of the rounds and increased the risk of medicines errors occurring.

Infection prevention and control procedures and standards of cleanliness were poor. Some areas of the home were dirty and unkempt, including people’s bedrooms.

People were not always protected from abuse. Staff understood how to identify abuse and who to report to if they suspected abuse was taking place. However, concerns were not always reported to external agencies for investigation as required.

People’s rights were not always protected because staff did not always understand the principles of the Mental Capacity Act 2005 or work within them. Depri

The inspection took place on 24 June 2016 and was unannounced. We returned on 28 June 2016 to complete the inspection. At the previous inspection in September 2014 we found improvements were needed in the Oakview unit as the temperature was not being effectively controlled and the environment was not adapted to meet the needs of people living with dementia. At this inspection we found the required improvements had been made.

Ashley Lodge is a care home with nursing. It is registered to provide care treatment and accommodation for up to 77 people. At the time of our inspection 68 people were living at the service. Ashley Lodge consists of the main building, Ashton House which has two floors. The downstairs unit mainly accommodates people who are physically frail and need nursing care. The upstairs unit accommodates people who have nursing needs but also who are living with dementia. The separate Oakview unit accommodates people who do not have nursing needs but who are living with dementia.

There was a manager in post who was in the process of applying for registration. They were highly thought of and demonstrated an enthusiasm and understanding of their role. 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 2014 we found improvements were needed to the environment of Oakview unit. At this inspection we found the required improvements had been made. Staff ensured people were not too hot or too cold and further adaptations had been made to maintain the independence of people living with dementia.

People were mainly very positive about the quality of care support and treatment they received at Ashley Lodge. They said they felt safely cared for and were able to raise any concerns with staff and management. There were clear policies and procedures in place to protect people from abuse and avoidable harm, which staff followed.

Risk to people's health and welfare was reviewed regularly and action had been taken to keep people as safe and as comfortable as possible. There were plans in place for responding to emergencies and untoward events. People's medicines were managed so they received them safely and as prescribed.

There were sufficient numbers of suitably trained, safely recruited staff deployed. They received appropriate training and good support to help them to carry out their role effectively.

Staff sought people's consent before carrying out care and treatment. Where people lacked capacity to consent to their care, staff had made best interest decisions in line with the Mental Capacity Act 2005.

People were given choice and had sufficient to eat and drink. People with complex nutritional needs were supported appropriately. People's health was monitored and the service had good links with health care professionals.

People were treated with kindness and respect and people and their visitors described a friendly and caring atmosphere. Care was provided in line with people's wishes and preferences and people were encouraged to remain as independent as possible.

The service was outward facing and had developed good links with the local community. People were encouraged to be involved in developing the service. There were robust quality assurance processes in place to ensure Ashley Lodge continued to improve.

We were assisted throughout this inspection by the home’s registered manager and deputy manager. We carried out a tour of the premises and were introduced to many of the people living at the home. At the time of the inspection there were 66 people accommodated at Ashley Lodge.

Many of the people living at the home were not able to tell us about their experiences because of their health conditions or because they had a diagnosis of dementia. We spoke with three people living at the home who were able to tell us about their experiences and with three relatives of people who lived at the home. Generally, people were very positive about the home and the way people were cared for. One person told us, “I have got no complaints and have been treated very well here”. Relatives told us that there was good communication with management and that the care and welfare of people was met at the home.

We found the home had good systems in place to assess and plan for people’s care so that staff were fully informed on how to care for people consistently.

The home had robust recruitment systems in place to make sure that only suitable and competent staff were employed to work at the home.

There were effective quality assurance systems in place to make sure that the quality of service was maintained and to make sure the service was responsive to people’s needs.

Records we looked at were up to date, accurate and were readily available when requested.

In this report the name of registered managers appear who were not in post and not managing the regulatory activities at this location at the time of the inspection. Their names appear because they were still on our register at the time of our inspection visit.

We spoke with people living in the home, all of whom told us that they were happy living there and were able to choose how they spend their days. We observed how care was being provided to help us understand the experiences of people using the service.

Staff communicated effectively with people using the service and supported them in ways that promoted their independence.

Support provided was person centred specifically tailored to people's needs. Health risks associated with individual's care and support were assessed and managed well, taking into account people's safety and their right to make choices.

The service had systems to ensure people were protected from the risk of abuse and their rights were respected and upheld. Staff had an understanding of safeguarding issues and how to report allegations of abuse.

We spoke with seven people who use the service. All confirmed that staff were caring and competent; one person stated that "they are always cheerful and ready to help”, another person said “they always have time for me."

The service had a system in place to gain the views of people who use the service, family and/or carers and staff in order to ensure a quality service was provided.

People who use the service and their relatives told us that staff respect people’s privacy and dignity and involve them in the way their care is carried out. They said that staff provide what they ask for and that personal care is given sensitively and in private. People told us they are consulted about the care they receive and are kept informed. Their choices were respected and acted upon, and they were asked if they wanted to be involved in activities going on in the home.

Relatives told us that they were involved in meetings with staff about the care their relative received. They said they were involved in care plans and decisions made about their relatives. A relative told us staff were quick to respond if they thought a doctor was needed.

People were complimentary about the food provided and said there was plenty of choice about what to eat. People were able to choose where to have their meal and support was provided as needed.

People told us they received their medication and they had no concerns about this aspect of the service. They told us that they were comfortable living in the home and that it was clean and well maintained.

People we spoke with were confident about staff responding promptly to the call bell system. They said that staff make sure they are comfortable when being supported to move between areas.

Relatives told us that they were able to raise concerns and these were acted on. They told us that they have regular meetings with the manager to discuss issues and receive updates about the service. People told us they were introduced to new staff and that the staff gave assistance in a sensitive and caring manner. People commented that staff “knew what they were doing”.

The service consists of the main house, referred to as Ashley Lodge and a separate house on the site called Oakview. Ashley Lodge provides nursing and residential care for up to 57 people, some of whom may have dementia. It is divided into four units. Oakview provides residential care only, for up to 20 people with dementia. When we visited there were 52 people living in Ashley Lodge and 14 in Oakview.

We carried out this inspection in response to concerns raised with CQC.

Our inspection team was made up of a lead inspector, a second inspector and an expert by experience. They helped answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

We spoke with the registered manager and 14 members of staff, some by telephone after the visit. We looked at care records for nine people using the service and observed care. We also spoke with 11 people living at the home, five relatives and a visiting health care professional.

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?

People were treated with respect and dignity by the staff. There was a person-centred approach to care and people told us they felt safe and happy living at the home.

Systems were in place to make sure that managers and staff learn from events such as accidents and incidents, concerns and investigations. This reduces the risks to people and helps the service to continually improve.

The home had proper policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS). Applications had been made appropriately to keep people safe using DoLS, and the registered manager had a good understanding of the procedures required.

The Oakview premises were not maintained at a comfortable temperature at all times, and were not adapted to meet the specific needs of people with dementia. This meant people in Oakview were not always safe. Other aspects of the facilities were well maintained and serviced regularly to minimise risks to people living in the home.

The staff rotas were reviewed to reflect people’s care needs and new staff were being recruited to provide a consistent team of permanent staff. This meant staffing to ensure that people’s needs were met.

Is the service effective?

People’s health and care needs were assessed and care was designed to meet their specific needs. People or their representatives were involved in writing their plans of care.

People were supported to have sufficient to eat and drink and action was taken if weight loss was identified.

Care plans reflected people’s specific health needs and staff monitored and reviewed changes in people health and sought professional advice or intervention when necessary.

Staff received effective induction, support and supervision to carry out their roles. They were encouraged to gain relevant qualifications.

Is the service caring?

People were supported by kind and friendly staff. Care staff were respectful and showed concern for people’s wellbeing in a caring and meaningful way. People’s comments included, “[Staff] listen to me if I refuse [aspects of care] and are respectful” and “It is lovely here, the food is very nice and they [the staff] are very kind.”

People’s privacy was respected and staff told us, for example, “We are respectful, we knock on doors and ask permission. We make sure people are covered if they are being washed”.

Is the service responsive?

People’s preferences, lifestyle history and interests were recorded and care and support was provided in accordance with people’s wishes. People’s views in relation to day-to-day living were sought.

The activities programme reflected people’s feedback, and activities including one-to-one visits, were available seven days a week.

Concerns, complaints and feedback was encouraged so the service could learn and improve.

Is the service well-led?

The service worked well with health and social care services to make sure people received their care they needed.

The service had systems in place for monitoring the quality of service and shortfalls were addressed promptly. As a result the quality of the service was continuingly improving.

Staff told us they were well supported and understood their roles. They were confident in how to raise concerns or report incidents. This helped to ensure that people received a good quality service.