Ashley House - Langport

At the last inspection we identified a breach of Regulation 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider had failed to ensure staff received sufficient training to enable them to carry out their roles. At this assessment improvements had been made to staff training and the provider was no longer in breach of regulation 18. Staff training had improved. Staff received training to meet the needs of the people they were supporting. Where staff told us they would benefit from additional training, the registered manager told us they would look into this. There were systems in place to manage medicines, we found some shortfalls in how staff were recording medicines. The registered manager was aware of and addressing this. The assessment of risk for a high-risk medicine was not in place, the registered manager confirmed they would complete this. Care records showed risks to people's health were assessed and managed by staff. Staff supported people safely in line with their risk assessments and management plans. There were enough staff available to meet people’s needs. Staff raised some concerns around the deployment of staff, the registered manager was addressing this prior to our assessment and had plans in place. Recruitment systems were in place, we found some gaps in auxiliary staffs’ employment records, which were rectified during the assessment. The provider had systems and processes to manage, follow up and learn from accidents and incidents. Staff told us they knew how to raise concerns and would do so if they were worried about safety or the quality of care. Where restrictions were placed on people’s liberty appropriate referrals were made to authorise this. The provider had systems to prevent and control infections and maintain the safety of equipment and the environment.

People’s needs were assessed and related care plans and risk assessments were developed. These care plans were reviewed involving people and their relatives as appropriate. Staff worked with health and social care professionals to make sure people received the care, treatment and support they needed. Our observations of the dining experience at the home was mixed, people were not always offered condiments or told what their meal was. On the second day of our site visit this had improved. The management team had systems and processes in place to meet people’s nutrition and hydration needs. Daily handover meetings were held and included discussions around people’s health and changing needs. People confirmed staff asked their consent before supporting them. Staff were aware of the principles of the Mental Capacity Act (MCA), MCA assessments and best interest decisions were in place for most decisions. We found 1 example where an MCA and best interest decision had not been completed. The registered manager addressed this during the assessment.

At the last inspection we identified a breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Systems and processes were not operated effectively to assess, monitor and improve the quality and safety of the service. At this assessment the systems to monitor the quality and safety of the service had improved and the provider was no longer in breach of regulation 17. There were a range of audits and checks carried out by the provider and registered manager. These identified areas of improvement and a service improvement plan was in place. Statutory notifications had not always been submitted as required to the CQC. We identified 2 statutory notifications had not been submitted. Retrospective notifications were completed by the registered manager during the assessment. All other notifications had been submitted as required. There was a visible and caring management team who, with staff, fostered a culture that delivered good quality care and outcomes for people in partnership with external professionals. The registered manager knew people well and was passionate about providing good quality and person-centred care. The registered manager adopted an open-door policy, and staff were encouraged to whistle blow if they felt the need. Staff felt confident to speak up and that they would be listened to. There were systems in place to share learning. Staff were aware of their roles and responsibilities. The provider had policies and procedures to make sure staff were fairly recruited and treated. The aims of the service were adopted by staff and staff worked well together as a team.