This inspection took place on 2 and 9 October 2018. The first day was unannounced. Ashton Grange 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. Ashton Grange is registered to provide nursing, care and accommodation to 31 people. There were 29 people living in the service when we visited. People cared for were mainly older people who were living with a range of care needs, including arthritis, diabetes and heart conditions. Most people were also living with dementia, some of these people could show behaviours which may challenge others. Most people needed support with their personal care, eating, drinking or mobility.

Accommodation was provided over two floors of a turn of the century house, which had been extended to the rear. The service was situated in a quiet residential street in Horsham.

The service had 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. The provider is Ashtonleigh Homes Limited who own another home in the area. The owner also provided a service in two other homes; these are registered as different legal entities.

The service was last inspected on 26 January 2016. It was rated as good at that inspection.

At this inspection, we identified a wide range of areas which needed to be addressed and the service is now rated as requires improvement.

The provider’s own quality audit systems had not identified some areas or ensured appropriate action was taken before our inspection to reduce people’s risk. Similar issues were identified at the other three services owned by the provider. Matters identified at this service included making sure appropriate standards of hygiene and infection control were maintained and certain aspects of medicines care and treatment were in place. The provider had also not ensured all people who had difficulties with consenting to care and treatment had relevant best interest decisions and Deprivation of Liberties safeguards (DoLS) considered. People had care plans but the provider had not identified in their quality audits that they did not consistently reflect their needs, were not always reviewed when necessary and were not always being followed by staff. National guidelines in relation to relevant areas such as diabetic care and prevention of pressure ulceration were being followed and reflected in people’s care plans.

We recommend the service follows NICE guidelines on care planning to support people who are living with diabetes.

People received a mixed approach from staff, some of whom did not show a kindly, caring approach. This lack of care was also shown at mealtimes where some people were not always attended to in the way they required, while other people received the assistance they needed. Some people who remained in their rooms were supported in a functional way by brief, infrequent visits. Other staff supported such people in a kindly understanding way. People who went to the lounge were supported by staff who engaged with them in an effective way.

There were enough staff on duty. Staff had been recruited in a safe way. Staff told us they were supported by the provider, including through the training they received. All staff were aware of their responsibilities in relation to ensuring people were safeguarded from risk of abuse.

Staff ensured the safety of people in some areas, including supporting people who needed assistance to move about in a safe way and when supporting them with certain aspects of their medicines care and treatment. People told us releva

The inspection took place on 26 January 2016 and was unannounced.

Ashton Grange Nursing Home provides accommodation and nursing care for thirty-one older people, living with dementia, who need support with their nursing and personal care needs. On the day of our inspection there were thirty-one people living in the home. The home is a large detached property situated in Horsham, it has two large communal lounges, a dining room and well maintained gardens.

The service had a 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 2008 and associated Regulations about how the service is run.

There were sufficient numbers of staff to ensure people’s needs were met and their safety maintained. Staff had received induction training and had access to ongoing training to ensure their knowledge was current and that they had the relevant skills to meet people’s needs. People were safeguarded from harm. Staff had received training in safeguarding adults at risk, they were aware of the policies and procedures in place in relation to safeguarding and knew how to raise concerns. People felt safe, one person told us “I feel very safe, there are always staff about, I like living here.”

Risk assessments had been undertaken and were regularly reviewed. They considered people’s physical and clinical needs as well as hazards in the environment and provided guidance to staff in relation to the equipment that they needed to use and the amount of staff required when assisting people. People were encouraged and enabled to take positive risks. People’s independence was not restricted through risk assessments, instead risks were assessed and managed to enable people to be independent. Observations of people assessed as being at risk of falls showed them to be independently walking around the home. There were low incidences of accidents and incidents, those that had occurred had been recorded and were used to inform practice. For example, accidents and incidents were monitored and reviewed to identify trends and minimise reoccurrence and changes were made as a result.

People received their medicines on time and told us that if they were unwell and needed medicines that staff provided these. One person told us “Staff are very pleasant, I had a splitting headache and I asked for something for the pain. The nurse came along and gave me some medicine to help.” People were asked for their consent before being offered medicines and were supported appropriately, being offered a drink to take their medicine safely and comfortably. Medicines were administered by registered nurses whose competence was regularly assessed. There were safe systems in place for the storage, administration and disposal of medicines.

People were asked their consent before being supported with anything. Mental capacity assessments had been undertaken to ensure that for people who lacked capacity appropriate measures had been taken to ensure best interest decisions were made on their behalf.

People had access to relevant health professionals to maintain good health. One person told us “The doctor comes to visit me here, it is usually a woman, which I am in favour of. If I ask for the optician to visit, they visit and carry out an eye test. The chiropodist comes to check my toes nails.” Records confirmed that external health professionals had been consulted to ensure that people were being provided with safe and effective care. People’s clinical needs were assessed and met and they received good health care to maintain their health and well-being.

People could choose what they had to eat and drink and felt that the food was good. For people at risk of malnutrition, appropriate measures had been implemented to ensure they received drink supp

We spoke with four of the 29 people who lived at Ashton Grange Nursing & Residential Home. People told us they were very happy with the quality of care staff employed. One person said, “I feel I have been well cared for. It is very pleasant place to live. I don’t think it can be improved upon.”

We also spoke with two relatives who were visiting. They also confirmed they were satisfied with the delivery of care. One relative told us, “I think it is very good. I have seen a lot of changes recently. There had been a high turn over of staff and a lot of uncertainty. But now, under this manager, I would consider it is levelling out. The manager is good at recruiting competent staff. Overall the level of care is very good. I don’t think my relative will get better care anywhere else.” Another relative said, “The care provided is of a very high standard. I have never had any issues or concerns. The manager is very efficient and approachable. I feel confident my relative is getting the care they need.”

We spoke with one member care staff who was on duty and had recently been employed. They told us about how they had been recruited. They told us they felt well supported by the manager whilst they learned about what was expected of them.

We also gathered evidence of the provider’s recruitment and selection process by looking at the new member of staff’s record. It demonstrated that the recruitment process was sufficiently robust to ensure care staff employed by the provider were fit to work with the vulnerable and elderly.

During our visit we spoke with 10 of the 27 people using the service and one of their relatives. People’s comments included,

“It’s great here. I just like it.”

“They’re very kind.”

Some people using the service were unable to communicate with us verbally because of their dementia care needs, so we observed their experience and how staff engaged with them. People were treated respectfully. We saw staff addressing people by their preferred names. Personal care was carried out in private and staff were discreet when asking about care needs.

We also spoke with two of the home’s owners, the manager, a nurse and two care staff.

We were concerned that thorough checks were not always made on staff before they started working in the home. For example, we found incomplete references and unexplained gaps in employment history.

People told us what it was like to live at this home and described how they were treated by the staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people living in care homes are treated with dignity and respect and whether their nutritional needs are met.

The inspection team was led by a CQC inspector joined by an Expert by Experience (people who have experience of using services and who can provide that perspective).

We used the Short Observational Framework for Inspection (SOFI) tool during this visit in the dining area, during lunchtime. SOFI is a specific way of observing care to help us understand the experience of people who could not talk to us.

24 people were resident in the home at the time of our visit. We spoke with five people who use the service and four visiting relatives who told us that:

People's care was provided by care workers who understood people’s care needs and that their privacy and dignity were respected. Comments received included, “Oh yes definitely,” “very much so,” staff always treat her with respect,” yes, probably excessively so.”

People had expressed their views and had been involved in making decisions about their care and treatment.

People told us that there was sufficient food and drink provided.

People told us they felt they or their relative were well cared for by the staff. The staff were very caring and responsive to their care needs. Comments received included, “Staff are always thoughtful and kind” and “some people here are marvelous.”

People knew who to talk to if they had any concerns about the care provided, and felt it was an environment where their concerns would be listened to and addressed.