Ashfield Nursing Home 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. The service is registered to provide care and support to older people with dementia or mental health needs. On the day of inspection there were 36 people living there.The inspection visit took place on the 4 October 2018. It was unannounced and was planned as a focused inspection, in response to concerns that had been raised with us since the last comprehensive inspection in July 2018. After that inspection we received concerns in relation to staffing levels, unsafe care, poor management and the impact on people using the service. As a result, we undertook a focused inspection to look at safe and well led. This report only covers our findings in relation to those areas. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Ashfield Nursing Home on our website at www.cqc.org.uk.
At this inspection we found continued breaches of Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014; plus, a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
The team inspected the service against two of the five questions we ask about services: is the service safe and is the service well led. This is because we were concerned the service was not meeting some legal requirements. No risks, concerns or significant improvement were identified in the remaining Key Questions through our ongoing monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.
Since the last inspection, there had not been sufficient improvement in the overall governance of the service. The management of medicines, infection control and staffing had continued to deteriorate and the service is now rated inadequate and means the service is 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 enough improvement is not made within this timeframe and 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 and 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.
On the day of inspection there was no registered manager in post. The previous registered manager left in August 2018 and de-registered with the CQC. However, the new manager, who was present throughout the inspection, was in the process of completing their registration with us. They were also supported by the provider and a registered manager from another service managed by the provider. 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 was a whistleblowing policy in place and staff knew how to escalate concerns to external organisations if they were concerned about people’s care. The manager had notified us of two safeguarding incidents. However, we found more incidents where people had been at risk of harm that had not been notified to us and it was not clear whether information had always been shared with the local authority or safeguarding team.
Risk assessments were in place for many aspects of care, but they were not always robust and were not always updated promptly after an incident or change of circumstances. Daily records were not completed contemporaneously. This meant staff did not always have access to up-to-date information and we were not assured that people received their planned care.
The manager told us that people needed 10 staff to meet their dependency needs. We checked the rota for October and found there was not 10 staff on any day of the month. We also found that some staff included in the rota were not able to provide personal care as they were new and had not completed their induction or provided all necessary pre-employment checks. This meant there was not enough trained and experienced staff on duty to meet the identified needs of people.
Processes regarding storage, administration and recording of medicines were inadequate. Medicines were not stored safely. One medicines room was not fit for purpose as it was too small and unhygienic. There were no hand washing facilities in the room and we found records and unused medicines discarded on the floor.
Medicines were not always administered safely. We found medicine errors in all three medicine records we looked at. These errors included – missed medicines, not administering the dosage prescribed and unsafe practice regarding covert medicines (hidden in food or drinks). Audits of medicines were not completed.
There was a history of non-compliance in respect of infection control and we found cleaning was still not a good standard. We found unclean communal toilets and offensive odours in people’s rooms and communal corridors. The provider had not made the improvements required from the last inspection to make surfaces more hygienic and easier to clean; apart from one shower room which had been renovated.
The service was not well led. The provider had not provided the management and resources necessary to make the improvements identified at the last inspection; and had been rated ‘requires improvement’ in well led, at the last three inspections. There was no registered manager in post. However, the new manager had been in post for nine weeks and was in the process of completing the registration process with CQC.
Quality assurance was inadequate and had not identified where improvements were required. For example, they had not identified medicine errors and inadequate cleaning. Many areas for improvement identified at the last inspection were incomplete which indicated they had not been well managed.
Information regarding risks to people was not always shared with relevant organisations and we did not always receive notification of incidents where people were at risk of harm.
Contingency plans in place to ensure the service was adequately staffed during this period of staff change, were not effective. The service was frequently understaffed in respect of the providers dependency tool, which concluded they required 10 staff on duty to meet people’s needs. This impacted on the providers ability to implement their improvement plan as they were now focused on staff recruitment and induction.
Healthcare practitioners who worked in partnership with the staff at Ashfield Nursing Home, said staff responded positively to feedback and followed guidance given to them about how to meet people’s individual care needs. They said staff did a good job caring for people with complex needs and in difficult circumstances.