Asher Nursing Home

Asher Nursing Home is a nursing home which provides personal care to those with long standing, complex mental health needs. The service can support up to 17 people. At the time of our inspection, there were 14 people using the service.

People’s experience of using this service and what we found

The service was not well-led. There was no robust or effective governance system in place to ensure the service was meeting regulations. The registered manager and provider had not maintained oversight of the service to ensure that people's safety was maintained.

There was not an effective system in place to ensure the environment was safe and clean. There was a significant risk of fire at the service due to people smoking in their rooms and this had not been robustly risk assessed.

Documentation had not been maintained to an appropriate standard. Care plans and risk assessments were out of date, inaccurate or missing. People's care was not always planned or delivered in a person-centred way as staff did not have access to up to date and relevant information about people's care and support needs.

Accident and incidents were not being accurately recorded and reported. It was not clear what investigations were being done following an allegation of abuse to prevent further risk. Not all safeguarding matters had been reported to CQC, this is a legal requirement.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. There was a significant lack of meaningful activity planned or taking place. This meant a condition of one person’s Deprivation of Liberty Safeguards (DoLS) was not being met.

Infection prevention and control (IPC) concerns were identified. Areas of the home were not suitably clean and this needed improvement to ensure people were safe and their dignity upheld.

Staff were not receiving regular supervision and told us that they did not always feel supported. There was a lack of consistent team meetings to allow ideas to be shared and improvements to be made to the service. Nurses had monthly meetings to specifically discuss clinical matters, however individual clinical supervision was not occurring consistently.

People told us they liked staff; we saw staff engaging with people in a kind and caring manner. The service worked with outside agencies to support people's mental health needs.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (published 17 September 2021).

Why we inspected

The inspection was prompted due to concerns received about lack of reporting or investigating potential safeguarding concerns, staffing levels, nutrition and hydration, and lack of activities. A decision was made for us to inspect and examine those risks. The overall rating for the service has changed from requires improvement to inadequate based on the findings of this inspection. You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Asher Nursing Home on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to safe care and treatment; person-centred care; safeguarding people; need for consent; and good governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

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.

Follow up

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions of the 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.

Asher Nursing Home is a residential care home providing personal and nursing care to people experiencing a range of complex or enduring mental health diagnoses. The service also provides care to people who require support with their physical health. The service can support up to 17 people, at the time of inspection there were 14 people living at the service.

Asher Nursing Home accommodates people in one adapted building across three floors. There is a lift providing access to all floors. The building is in a residential area of the city close to public transport and public recreational areas.

People’s experience of using this service and what we found

We have made recommendations about following Public Health advice about COVID-19, record keeping and monitoring deprivation of liberty.

People were involved in their care planning, they felt that staff and managers supported them in their goals. People were supported to access information and advice to make informed decisions about their health and wellbeing.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People felt safe and received person centred support tailored to manage their particular needs with them. People were asked their views about the service and felt listened to. Staff got to know them well.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 15 May 2018).

Why we inspected

We received concerns in relation to staffing levels and how people’s risks were being managed. This included health risks and management of people’s deprivation of liberty. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe and well led section of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Asher Nursing Home on our website at www.cqc.org.uk

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

When staff were recruited, their employment history was checked and references obtained. Checks were also undertaken to ensure new staff were safe to work within the care sector. People were cared for in a clean and hygienic environment and appropriate procedures for infection control were in place.

Staff had received essential training and there were opportunities for additional training specific to the needs of the service, such as the treatment of specific infections and palliative care (end of life).

The provider undertook quality assurance reviews to measure and monitor the standard of the service and drive improvement. They had developed a strategic action plan to ensure improvement was sustained.

A registered manager was 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 and associated Regulations about how the service is run.

Staff were knowledgeable and trained in safeguarding adults and what action they should take if they suspected abuse was taking place. Staff had a good understanding of equality, diversity and human rights.

Medicines were managed safely and in accordance with current regulations and guidance. There were systems in place to ensure that medicines had been stored, administered, audited and reviewed appropriately.

People were happy and relaxed with staff. They said they felt safe and there were sufficient staff to support them. Staff had received both supervision meetings with their manager, and formal personal development plans, such as annual appraisals were in place.

Risks associated with the environment and equipment had been identified and managed. Emergency procedures were in place in the event of fire and people knew what to do, as did the staff.

People were being supported to make decisions in their best interests. The registered manager and staff had received training in the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). Accidents and incidents were recorded appropriately and steps taken to minimise the risk of similar events happening in the future.

People were encouraged and supported to eat and drink well. There was a varied daily choice of meals and people were able to give feedback and have choice in what they ate and drank. Health care was accessible for people and appointments were made for regular check-ups as needed.

People felt well looked after and supported. We observed friendly relationships had developed between people and staff. Care plans described people’s preferences and needs in relevant areas, including communication, and they were encouraged to be as independent as possible. People’s end of life care was discussed and planned and their wishes had been respected.

People chose how to spend their day and they took part in activities. They enjoyed the activities, which included, bingo, arts and crafts, park walks and themed events, such as visits from external entertainers. People were also encouraged to stay in touch with their families and receive visitors.

People were encouraged to express their views and said they felt listened to and any concerns or issues they raised were addressed. Technology was used to assist people’s care provision. People's individual needs were met by the adaptation of the premises.

Staff were asked for their opinions on the service and whether they were happy in their work. They felt supported within their roles, describing an ‘open door’ management approach, where managers were always available to discuss suggestions and address problems or concerns.

We undertook this unannounced comprehensive inspection to look at all aspects of the service and to check that the provider had followed their action plan, and confirm that the service now met legal requirements. We found improvements had been made in the required areas. However, we identified a further breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to recruitment practices. Additionally, areas of improvement were identified in relation to infection control, staff training and management oversight of the service.

The overall rating for Asher Nursing Home remains as requires improvement. We will review the overall rating of requires improvement at the next comprehensive inspection, where we will look at all aspects of the service and to ensure the improvements have been made and sustained.

Asher Nursing Home is a mental health nursing home and registered to provide accommodation and care, including nursing care for up to 17 people, with a range of enduring and complex mental health needs. On the day of our inspection there were 17 people living at the service, who required varying levels of support.

A registered manager was 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 and associated Regulations about how the service is run.

When staff were recruited, their employment history was checked and references obtained. Checks were also undertaken to ensure new staff were safe to work within the care sector. However, we found that for staff who were recruited before 2012, that no DBS (Disclosure and Barring Services) check had taken place. This placed people at potential risk of receiving care from staff that were not safe to work with vulnerable people. This is a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and is an area of practice that needs improvement.

Procedures in relation to infection control were not robust and this has been identified as an area of practice that needs improvement.

Staff had received essential training and there were opportunities for additional training specific to the needs of people, included managing behaviour that may challenge others. However, we saw that several members of staff had not received essential updated ‘refresher’ training in a timely manner. This is an area of practice that needs improvement.

The provider undertook quality assurance reviews to measure and monitor the standard of the service and drive improvement. However, we found issues in relation to management oversight and acting on known concerns. For example, when we raised our concerns with the management of the service in relation to historical DBS checks not taking place, we were told that the management of the service was aware of these issues, but had not acted upon them. Additionally, it was evident that despite having adequate processes and a training matrix in place, essential updated ‘refresher’ training not being made available in timely way. We have identified this as an area of practice that needs improvement.

People were happy and relaxed with staff. They said they felt safe and there were sufficient staff to support them. One person told us, “They look after me well, they are usually good to me”. Staff were knowledgeable and trained in safeguarding adults and what action they should take if they suspected abuse was taking place.

People chose how to spend their day and they took part in activities in the service and the community. Where appropriate, people were also encouraged to stay in touch with their families and receive visitors.

Medicines were managed safely and in accordance with current regulations and guidance. There were systems in place to ensure that medicines had been stored, administered, audited and reviewed appropriately.

People were being supported to make decisions in their best interests. The registered manager and staff had received training in the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS).

Accidents and incidents were recorded appropriately and steps taken to minimise the risk of similar events happening in the future. Risks associated with the environment and equipment had been identified and managed. Emergency procedures were in place in the event of fire and people knew what to do, as did the staff.

People were encouraged and supported to eat and drink well. There was a varied daily choice of meals and people were able to give feedback and have choice in what they ate and drank. One person told us, “The food is really good”. Special dietary requirements were met, and people’s weights were monitored with their permission. Health care was accessible for people and appointments were made for regular check-ups as needed.

People felt well looked after and supported. We observed friendly relationships had developed between people and staff. One person told us, “They look after me well”. Care plans described people’s needs and preferences and they were encouraged to be as independent as possible.

People were encouraged to express their views and had completed surveys. Feedback received showed people were satisfied overall, and felt staff were friendly and helpful. People said they felt listened to and any concerns or issues they raised were addressed.

Staff were asked for their opinions on the service and whether they were happy in their work. They felt supported within their roles, describing an ‘open door’ management approach, where managers were always available to discuss suggestions and address problems or concerns. Staff had received both one-to-one and group supervision meetings with their manager, and formal personal development plans, such as annual appraisals were in place. One member of staff told us, “I had supervision a month ago. They are very keen on supervision. It can be very stressful working in mental health, so it’s good to be able to feed back”.

We spoke with the registered manager, the deputy manager and two members of staff. We also looked at relevant documentation, including training records, supervision and appraisal schedules.

The manager told us that since the last inspection, staff training had been reviewed, with the area manager, to ensure that all mandatory (essential) training was up to date. This was supported by the training matrix that we were shown. We found that appraisals had been reinstated and all staff had received formal supervision, which was now being provided on a regular basis.

One member of staff told us 'It's definitely improved. We get lots of support, which is important because it can be challenging and get very stressful here."

The service had a manager in post. We saw evidence that the manager was in the process of applying for registration with the Care Quality Commission.

We spoke with eight people who used the service. During the inspection, we spoke with the manager, a registered nurse, the chef and three care staff.

Below is a summary of what we found. The summary describes what people who used the service and the staff told us, what we observed and the records we looked at. If you want to see the evidence supporting our summary please read the full report.

Is it safe?

People told us that they felt safe in the care of Asher Nursing Home.

People were safeguarded from the risk of abuse or harm.

Staff demonstrated a sound understanding of safeguarding vulnerable adults and knew how to report any concerns of abuse or harm.

People could freely access the local community and could come and go from the service as they pleased.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Deprivation of Liberty Safeguards. We found the location to be meeting the requirements of the Deprivation of Liberty Safeguards (DoLS).

Systems were in place for staff to learn from incidents, accidents and near misses

Is it effective?

People had their needs assessed and individual care plans were devised. Before anyone joined the service, a pre-admission assessment took place.

Care plans were detailed and provided personalised information which enabled care staff to provide care and treatment which was individual to that person.

People maintained good health. The service worked closely with GPs, care coordinators and the local authority.

Systems were in place to monitor, assess and improve the quality of the service. Feedback was regularly obtained from people who used the service and their relatives.

Complaints were handled and resolved appropriately.

We found that people were provided with appropriate nutrition and had a choice in relation to the food options available. The service offered a variety and range of meal options. A menu was displayed and people had access to hot and cold drinks throughout the day. People spoke positively of the food provided.

Is it caring?

People spoke positively of the care provided.

Staff demonstrated a good understanding of the care needs of people who used the service.

People were encouraged to treat the service as their own home.

People were treated with dignity and respect.

Staff spoke with fondness about the people they supported.

Is it responsive?

People had their needs assessed and support was sought where necessary.

Where's people's health had rapidly deteriorated we saw that the service took appropriate action.

People had access to activities. We received mixed comments from people about the opportunities of social stimulation and activities.

Is it well-led?

Throughout our inspection, staff spoke positively about the culture of the service and told us it was well-managed and well-led.

Staff we spoke with had a clear understanding of why they were there and what their roles and responsibilities were.

The service had a business continuity policy in place. This made sure that each service had a plan in place to deal with foreseeable emergencies. This would reduce the risk of people's care being affected in the event of an emergency such as flooding or a fire.

Supervisions and appraisals were not regularly provided to care staff to enable professional development.

Training records demonstrated that staff did not receive up to date training when required.

We spoke with the acting manager and two members of staff. We observed staff interacting with people who used the service. We found that staff used protective personal equipment (PPE) appropriately.

There were effective systems in place to reduce the risk and spread of infection.

Staff were trained in infection control and staff we spoke with confirmed they have regular training in infection control. One staff member told us, 'We've made great progress with cleanliness especially as this is a mental health home and often we work with people who have previously self-neglected or been homeless.'

We observed the care provided and looked at supporting documentation. We spoke to four members of staff, the deputy manager and the area manager. We talked briefly with people who used the service.

We found there had been an improvement in the overall level of care and support that people received. Records showed that people's care needs had been assessed, planned, reviewed and delivered in line with their individual care plan.

Staff were well trained and demonstrated a good knowledge of people's needs. Recruitment procedures were robust and staffing levels had been improved and were sufficient for the needs of those who used the service.

The overall level of staff support, supervision and morale had improved. This provided them with the necessary back up to carry out their role and to meet people's needs.

There were better systems in place to identify, assess and manage risks to people who used the service.

People who used the service were able to contribute to decision making and their views were taken into account.

The people we spoke with told us they were generally happy with the care they had received and with the staff team.

Staff we spoke with said that they had undertaken safeguarding vulnerable adults training, and people we spoke with told us that they felt safe and knew who to talk to if they had any concerns.

Staff we observed had an understanding of the support needs of people who used the service. However we found that some of the documentation used for care planning had not been reviewed regularly to ensure that the information detailing the care to be delivered had been up to date.

During our inspection, staff we spoke with confirmed that they had received relevant training, but told us that they had not always felt supported by the service to carry out their roles effectively. We looked at staffing rotas and during our inspection observed levels of staffing. We saw that the service did not have enough qualified, skilled and experienced staff to meet people's needs at all times.

The service had quality assurance systems in place to monitor the quality of the service provided and to gain the views of the people who used the service, but at the time of our inspection, some of these systems had not been used for some time, or were not being used at all.