This inspection took place on the 16 and 17 January 2019.

At our last inspection on 10 November 2017 we found five breaches of the regulations in relation to person centred care, consent, safe care and treatment, good governance and staffing.

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 key questions safe, effective, responsive and well led to at least good. We found the service had made improvements in the key questions of safe, effective, caring and responsive. However, the service was still in breach of the regulations for the key question well led. This is the third time the service has been rated as overall requires improvement.

Aspray House 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.

Aspray House accommodates 64 people in one adapted building. Care is spread over four separate units each of which have adapted facilities. Many of the people at Aspray House were living with dementia. At the time of our inspection there were 63 people using the service.

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.

People had risk assessments in place and in the majority of the files we looked at information on mitigation of identified risks was present. However, where this information was not clear this put people at risk of unsafe care. Information was sent after the inspection to show how this had been rectified but this indicated quality assurance systems needed to be further embedded to improve the quality of risk assessments.

Medicines at the service were managed safely. The service had systems in place to respond to and manage accidents and incidents.

Staff were recruited safely at the service and there was a robust checking process to ensure new staff and current staff were safe to work with vulnerable people.

Staff understood their safeguarding responsibilities and how to raise concerns. All staff knew how to whistleblow if they thought their initial concerns had not been acted upon by the service.

People at the home told us they felt safe and that staff attended to their needs. Relatives felt there were not enough staff in particular at weekends. We viewed records which showed staffing levels were maintained during the weekend and that the use of agency staff had reduced.

The service was very clean and there was no malodour throughout the home. Staff minimised the risk of infection and contamination by following good hand hygiene and by wearing appropriate protective equipment.

Effective care was given to people from staff who had been well trained. Staff received regular supervision and training specific to their role which was up to date. People and their relatives commented on how well staff had been trained and noticed if a new member of staff was currently being trained.

People received an assessment of need before they moved into the service which involved the person and their families where appropriate.

People were offered a varied menu and able to choose alternatives if they wanted something different to eat. We observed positive dining experiences and where people were supported to eat this was done in a calm and dignified way. We received mixed feedback on the food. People expressed that the food was not warm by the time it reached them and there were issues around the consistency of the food.

People were supported to have maximum choice and control of their lives and staff supported them in the

This inspection took place on 10, 13 and 16 November 2017. The first day of the inspection was unannounced.

Aspray House is a care home with nursing for up to 64 people. People in care homes receive accommodation and nursing or 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.

Aspray house is divided into four units providing nursing care to older adults. It is a large purpose built care home that is fully accessible to people with mobility needs. At the time of our inspection 61 people were living in the home. Many of the people living in the home were living with dementia.

The home did not have a registered manager. The last registered manager had left recently, and the new home manager was in the process of applying to register with us. 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 the last inspection in January 2017 we asked the provider to take action to make improvements in relation to choking risk assessments and staff training in relation to choking. The provider had taken action to address these concerns.

At this inspection we found that needs assessments, care plans and risk assessments lacked detail and were not personalised to each individual. They lacked detail regarding care preferences including personal care, dietary needs and end of life wishes. Records of care did not show people were supported to have their needs met.

The home had high agency use and this affected people’s experience of care and views on the attitude and number of care staff.

Staff had not received the training and support they needed to perform their roles. Staff were using physical intervention when supporting people with personal care and had not had training on how to do this in a safe way.

The home had not always sought consent in an appropriate way, and some care files contained conflicting information about people’s capacity to consent to care. Staff did not demonstrate a sound working knowledge of the Mental Capacity Act 2005.

The governance arrangements in place had identified issues with the quality and safety of the service, but actions in place had not been effective in improving the experience of people living in the home.

Staff were knowledgeable about safeguarding adults from harm, and the provider took appropriate action to investigate and respond to allegations of abuse and other concerns raised. Some people told us the previous manager had not responded to their concerns, and the new manager addressed this immediately.

The home was clean and well maintained. The home was coming to the end of a programme of refurbishment which included replacing flooring which had previously been malodourous.

People living in the home had complex healthcare needs. They received support to access healthcare services and the home worked appropriately with healthcare professionals to ensure people’s needs were met. People were supported by qualified staff to take their medicines as prescribed.

Staff demonstrated they understood how to provide compassionate care, and how to promote people’s dignity. Staff demonstrated they understood the impact people’s sexual orientation might have on their experience of care. However, sexual orientation was not included as part of the care assessment and planning process. We have made a recommendation about supporting people who identify as lesbian, gay, bisexual or transgender.

The provider had a clear complaints policy and the new manager had introduced systems to ensure people and relatives were able to provide feedback about their experience of the home. Some people said their pre

This focused inspection was prompted by notifications of incidents following the deaths of two people who used the service. These incidents are subject to coroner investigations and as a result this inspection did not examine the circumstances of the incidents. However, the information shared with CQC about the incidents indicated potential concerns about the management of choking. This inspection examined those risks.

The focused inspection of Aspray House was carried out on 19 January 2017. Focused inspections do not look at all five key questions of safe, responsive, caring, effective and well-led, they focus on the areas indicated by the information that triggered the concerns. During this inspection we looked at the key questions of 'safe' and 'effective’.

We last inspected Aspray House on 8 & 10 August 2016. At the time the service was rated as ‘Good’.

Aspray House is a nursing and residential home that provides care for up to 64 older people some of whom may be living with dementia. There were 63 people using the service when we visited.

There was a registered manager at the service at the time of our 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.

Risk assessments did not always consider associated signs and symptoms, specific to the person that could indicate potential or actual risk of choking. Care staff were not always confident what to do in an emergency medical situation.

We observed interactions between staff and people living in the home and staff were kind and respectful to people when supporting them. People were provided with a choice of food and drink and supported to eat healthily. However some staff were not sure of the food they were feeding people.

People had access to health care professionals and were supported to lead healthy lifestyles.

The registered manager had put some safety measures in place to minimise the risks for people at risk of choking.

We inspected Aspray House on 8 & 10 August to check that improvements to meet legal requirements planned by the provider after our 20 & 21 October 2015 inspection had been made. This was an unannounced inspection.

On the 20 & 21 October 2015 we carried out an unannounced follow up inspection of the service. We found concerns on the following; risk assessments were not always comprehensive, staff were not always supported with supervision and appraisals, and care plans were not always up to date. We issued two requirement actions. The local authority also had concerns about the service and have been monitoring and working with the service provider to improve the quality of care provided. At this inspection we found improvements had been made.

Aspray House is a nursing and residential home that provides care for up to 64 older people some of whom may be living with dementia. There were 63 people using the service when we visited.

There was a registered manager at the service at the time of our 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.

The quality and consistency of the risk assessments and the care planning process had improved since our last inspection. People’s needs were assessed and their preferences identified as much as possible across all aspects of their care. Risks were identified and plans in place to monitor and reduce risks.

The home environment was clean and we saw domestic staff throughout the inspection using personal protective equipment such as gloves and disposable aprons. However there was a strong malodour on the ground floor. We have made a recommendation about the management of odour at the home.

We found people were cared for by suitably qualified, skilled and experienced staff. Robust recruitment and selection procedures were in place and appropriate checks had been undertaken before staff began work. There were sufficient staff deployed to provide care and staff were supported in their roles with training, supervision and appraisals. Staff understood their responsibility to provide care in the way people wished and worked well as a team. They were encouraged to maintain and develop their skills through relevant training.

We observed interactions between staff and people living in the home and staff were kind and respectful to people when supporting them. Staff knew how to respect people’s privacy and dignity. People and their relatives were supported to attend meetings where they could express their views about the service. There was a range of activities on offer throughout the week. Most activities took place within the home, such as singing, puzzles and quiz games.

People were able to make choices about most aspects of their daily lives. People were provided with a choice of food and drink and supported to eat healthily. People had access to health care professionals and were supported to lead healthy lifestyles.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The registered manager understood this legislation and had submitted DoLS applications for some people living at the home. Staff were aware of their responsibilities under this legislation and under the Mental Capacity Act (2005).

The home had a registered manager in place and a management structure with clear lines of accountability. Staff told us the service had an open and inclusive atmosphere and senior staff were approachable and accessible. The service had various quality assurance and monitoring mechanisms in place. These included surveys, audits and staff and resident meetings.

This visit was carried out in response to concerns raised anonymously by people who had witnessed care and treatment at Aspray House. We visited at the weekend with an expert in the field of mental health and dementia. Following our visit we received one more concern. We spoke to staff, relatives and people who used the services. All of them told us that they were happy with the care provided at Aspray House.

We found that people’s needs were assessed and care and treatment was planned and delivered in line with their individual care plan. Care and treatment was planned and delivered in a way that was intended to ensure people’s safety and welfare.

Staff had undertaken recent fire safety and basic life support training. Although there were arrangements in place to deal with foreseeable emergencies, we found that care staff had limited information about the evacuation procedure in the event of a fire.

The Care Quality Commission had received information of concern about the arrangements for the handling of medicines.

At this inspection we looked at medicines storage, medicines and records about medicines for people using the service and reviewed documents supplied by the service.

As part of this inspection we looked at the medicine administration records for 39 people. We saw appropriate arrangements were in place for recording the administration of medicines. These records were clear and fully completed .The records showed people were getting their medicines when they needed them, there were no gaps on the administration records and any reasons for not giving people their medicines were recorded. If people were allergic to any medicines this was recorded on their medication administration record chart. This meant people were receiving their medicines as prescribed.

We spoke to eleven people who used the service and some relatives. We found that most people were happy with care they received. One person said, " Staff, come when, I need them or call. They are good and patient with me." A relative said, "I have no concerns so far."

We found that people were cared for in premises that were adequately maintained. Equipment was readily available, regularly checked and in a good state of repair.

We observed a medication administration round and found that there were procedures in place to ensure that medicines were stored, administered and discarded in an appropriate manner. Staff told us that only staff who were assessed competent were allowed to administer medication.

Staff told us that they had regular supervision, staff meetings and attended training sessions. Staff told us that they felt supported by their manager.

We reviewed care plans and found them to be individualised and reflecting the individuals current condition. Appropriate risk assessments were completed and staff were aware of these. However, people were not always aware of the contents of their care plans or if they were updated.

People told us that they had no concerns about the care they received. Staff, people, and relatives were aware of the complaints procedure and were able to express their concerns when the need arose. One person felt it might impact on them negatively if they spoke to us about concerns. However, a relative spoke on their behalf.

People told us that they were satisfied with the care they received. One person said “the care is ok, I cannot complain. I prefer to stay in my room most days.” We saw staff obtaining consent before giving care and relatives said they were kept informed and involved in care. The provider had ensured that staff were trained in safeguarding vulnerable adults. People told us that they felt safe and comfortable. One person said “the care is good. Most staff are helpful and the manager is approachable.” A relative told us that “care is pretty good here. Staff manage to keep mum calm which is a great relief.”

We found that adequate checks were done before recruiting staff and an induction programme was completed by all staff. For staff who had committed proven offences we saw documentary evidence that the home’s disciplinary policy was followed. Risk assessments and care plans were up to date and person centred. We observed that call bells were answered in a timely manner. However on the first floor most people did not have their call bell in reach. We challenged this and were told that some people who stayed in their rooms were unable to use the bell appropriately.

Staff had been trained on how to use equipment and manuals were readily available. However there were gaps in service records for equipment used to take temperature blood pressure and blood glucose monitoring. This left people vulnerable to the potential of faulty equipment being used to deliver their care.

People told us what it was like to live at this home and described how they were treated by 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.

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 to us.

The inspection team was led by a Care Quality Commission (CQC) inspector joined by a practising professional. We spoke to six people who used the service and two relatives. Four out of six people said they enjoyed the meal times and that they had adequate choice of food and drinks through out the day. However three people who preferred to have their meals in their rooms told us that their meals arrived cold.

People who used the service told us they felt safe at the home, were involved in their care and could talk with the manager or other staff if they had a worry or concern.

People who used the service told us that staff were kind and respected their privacy and promoted their independence. One person said, “Staff are patient with me when, I can’t walk as fast as I used to”. Another person said, “Staff always respond when I tell them I need to use the bathroom”.

People told us staff understood their needs and provided them with the care and support they needed in the way that they wanted. They told us their religious and cultural needs were met by the home, and staff spoke to them in the language that they understood. One person said “they all know how I like my tea”.

One person said “I like the staff. I get on well with them”. Four out of six people referred to staff as being very good. One person said, “It’s a lovely place. People are very nice”.

We talked to those people who were able and happy to talk to us. We also talked to relatives and visitors of some people who, because of their assessed needs, were not able to talk to us directly. We also spoke with some people who visit the home regularly.

People made a range of positive comments about the home including:

“I had the chance to have a good look around before I moved in”.

“They come round every day to ask you what you want for dinner”. “The place is pretty good, I feel safe here”

“They are very good; they keep the place clean and tidy”.

A community matron told us the Primary Care Trust input she was providing to Aspray House was new, approximately three months at the time of the visit, and she told us: “(that the home) was going in the right direction”.

We undertook this focused inspection on 20 and 21 October 2015 to check the provider had improved and now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Aspray House on our website at www.cqc.org.uk

On the 13 and 14 January 2015 we carried out an unannounced comprehensive inspection of the service. We found concerns for the management of medicines, risk assessments were not always comprehensive, staff were not always supported with supervision and appraisals, and care plans were not always up to date. We issued three requirement actions. The local authority also had concerns about the service and have been monitoring and working with the service provider to improve the quality of care provided. Many of the concerns we found during this inspection reflected the same concerns raised by the local authority staff who had visited the service since our last inspection in January 2015.

Aspray House is a nursing and residential home that provides care for up to 64 older people some of whom may be living with dementia. There were 58 people using the service when we visited.

There was not a registered manager at the service at the time of our inspection. Although there was a manager in place since 6 September 2015. At the time of our visit the manager was applying for registration with the Care Quality Commission. 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 improvements made at the service were mainly in respect of the approach of the new manager in the role. The manager had recognised the previous quality assurance processes reflected more a tick box system exercise and did not reflect quality. We saw evidence that a new robust monitoring and auditing system had recently been introduced. Records showed this system had identified concerns we found during the inspection and what action the service was taking.

Staff were now receiving regular supervision however the quality of these supervisions varied on who was offering the supervision. Not all staff were receiving annual appraisals. The quality of the completed appraisals varied from incomplete forms and lack of detail including a lack of goals and target dates. The policy for appraisals stated that each member of staff would receive one annually.

Medicines were now stored and administered safely. Individual risk assessments were in place for people, to help protect them from harm. However, the assessments and care plans were not always comprehensive.

Whilst we found evidence to demonstrate that some of our concerns had been addressed, we found continuing breaches of two legal requirements because improvements were insufficient and further concerns were identified. This continued to put people using the service at unnecessary risk of receiving inappropriate or unsafe care. We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.