Ashmore Nursing Home

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Improvements are needed to staffing levels, and we identified a continued breach of the legal regulations in relation to staffing. People and their relatives raised concerns with us about low staffing levels and described how the levels of staff impacted on the quality of care and safety of people. Shortfalls in staffing were acknowledged by the registered manager but as a short-term issue and they assured us that some staff appointments had been made. However, this was identified as an issue at the previous inspection and has not been fully resolved. Whilst some improvements have been made to the oversight and management of clinical risks, we identified safety issues in the environment. Once we raised this with the registered manager, they told us that action would be taken, however we were not assured that learning in creating a culture of safety had been embedded. Care plans and risk assessment tools were in place however, there was a need for greater transition planning to support new residents, particularly those people who were experiencing distress and low mood. Staff had undertaken training in safeguarding, and we saw examples where the registered manager had worked with the safeguarding team to investigate and address concerns. Medicine practice had improved overall, and people told us that they received their medicines when they needed them. However, we identified some areas of concern, and the service did not always have effective oversight systems in place to identify issues independently.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We received mixed feedback as to whether transitions between services were managed well. Some relatives told us that their family member had good access to GPs and other health professionals, such as chiropody and opticians but others told us that things did not always go smoothly which meant that there were sometimes delays in accessing treatment. 5 people moved into the service shortly before our assessment. Care plans were in place which provided some guidance to staff on people’s needs and preferences but there was a need for greater transition planning to support new residents, particularly those people who were experiencing distress and low mood. We asked the service to conduct a risk assessment and seek specialist support for one person to ensure that they received the support they needed. People and their relatives told us that communication was generally good, and they were kept up to date with changes in their relative's needs and any incidents which occurred. On the day of the assessment, we noted that a member of staff accompanied a person to hospital to assist them.

Staff described working with a variety of health and social care professionals to ensure the physical health and wellbeing of people they supported. We saw for example that they had been in contact with Speech and language therapy (SALT)and tissue viability teams to review people’s needs.

No specific concerns were raised by partner agencies.

The registered manager reviewed incidents and accidents to identify any trends or themes. They described the actions that they took to reduce the likelihood of a recurrence and to learn lessons from what happened. These actions included additional training on areas such as pressure care and closer monitoring of fluids. As part of the assessment, we reviewed recent incidents and accidents and asked the registered manager to review how people who have unwitnessed falls were being monitored post fall, as this was not always clear from people’s records. Sensor mats were being used to alert staff to people at risk of falls mobilising but the rationale for the location of the device was not clearly documented and therefore not clear, placing people at risk of inconsistent care. People at risk of pressure ulcer had appropriate pressure relieving equipment in place. Records showed that people were assisted to reposition at regular intervals in line with their risk assessment. There were clear arrangements in place to support people with catheter care. Records showed the amounts of fluid people consumed and the registered manager confirmed that this information was regularly reviewed by the registered nurses. The manager acknowledged that the review could be better documented and agreed to address and build into the auditing arrangements. There were systems in place to ensure vital information was shared with the necessary health professionals. The service used an electronic care planning system, and this produced a hospital passport which provided a summary of people’s needs and assisted communication with the hospital.

People and their relatives expressed concerns about staffing levels and how some incidents were dealt with. However overall, most people told us that their relatives were safe, and they were supported by staff who were kind.

Staff had undertaken training in safeguarding and understood procedures and what actions to take if they had concerns. They all expressed confidence that the registered manager would take appropriate action if concerns were raised.

Throughout the assessment we observed people being supported safely by staff.

The registered manager was aware of previous safeguarding concerns and had worked with the local authority to investigate and respond to any issues raised. Safeguarding policies and procedures were in place however notifications were not always completed as required to CQC when safeguarding alerts were made.

Relatives and people using the service told us that they had been involved in the formulation of their care plans and had discussions in relation to minimising risks to their safety. However, some relatives had concerns about how risks were being managed and the impact of staffing shortfalls. They had concerns about their relative falling and the checks on people who were not able to use a call bell to summon assistance. Relatives described finding their relative soiled and had some concerns about the possible impact on their family member's skin. One person raised specific concerns regarding the use of prescribed drink thickeners in fluids and how it was not always mixed properly, we asked the registered manager to follow this up.

The registered manager told us that an assessment of risk was undertaken as part of the admission processes and where possible they tried to involve people in considering how best to minimise the impact of any control measures on people. There was a culture of positive risk taking with a view to improving people’s quality of life. One person for example was noted to like junk food but this was acknowledged, and staff were to encourage where possible healthy choices. Another person was noted to enjoy pottering, but they had been identified as being at high risk of falls. The risk assessment noted that the benefits of being able to freely move around outweighed the risks from falls.

Most people spent their time in their bedroom and buzzers were not always within reach. Some people were calling out for assistance. A small group of people attended the dining room for lunch and while a member of staff was present, they were supporting one person to eat, and others would have benefited from greater monitoring and prompting. Staff had a good understanding of people’s needs and people were observed to have the equipment they needed such as pressure relieving mattresses and cushions to reduce the risk of harm. We observed staff assisting people to mobilize in a safe way and staff provided people with clear instructions and worked at the person’s pace.

Standardised assessment tools such as Waterlow, a skin pressure risk assessment tool, and MUST a nutritional screening tool, were used to assess risks to people and inform care planning. People had care plans and risk assessments in place to guide staff on how to mitigate risks. Records showed that people were assisted to reposition at regular intervals in line with their risk assessment.

People and relatives did not identify any current safety issues although some did express some concern about the impact of the lift breaking down earlier in the year which meant there was no easy and accessible access between the 2 floors.

The registered manager told us that they had sought specialist advice from a safety consultant and had started to address the environmental areas already identified however some areas required substantial financial investment and had not yet been actioned. Changes had been made to the entrance of the service which meant that the risks of people leaving the service unobserved had been reduced.

We found processes were not always effective in identifying and ensuring that the environment was safe for people. People were supported in an environment which presented risks and potential hazards.

Records showed that risk assessments were undertaken, and the environment was checked to reduce the likelihood of harm. The checks undertaken included a review of fire safety, moving and handling equipment and water temperatures. However, there were omissions, and we identified that the risks surrounding the stairs had not been fully assessed and they were supporting people who were mobile, had a diagnosis of dementia and had been identified as being at the risk of falls. Appropriate and timely action was not always taken when issues were identified. For example, the temperature of the water in one of the bathrooms had been recorded as being above recommended levels, but no action was taken. When we raised this with the registered manager, they took the bathroom out of use and flagged for repair. Similar issues were identified with the gates in the garden, which were not secure and meant that people could leave the service unobserved and access the industrial units at the rear. This had been identified as needing addressing following our last inspection but had not been actioned. When we raised this with the registered manager, they told us that urgent action would be taken and subsequently confirmed that the security of the garden areas had been improved. These risks had been identified at our last inspection visit and not fully addressed at this inspection. Auditing processes were therefore not well developed as they had not identified insufficient action on these safety shortfalls. There was an overall lack of scrutiny at provider level.

People and most relatives told us that their family member was impacted by shortfalls in staff at the service. They described their relatives as having to wait for long periods before being assisted to the toilet and expressed concern that they spent significant periods of time in their rooms with little activity to occupy them. One person told us, “They are very short of staff here. All we do is eat, drink and sleep. It is so boring, there are no activities. The staff are kind and do their best…. At home I used to have daily showers and was told I could have them here, but staff tell me they don’t have time.” A relative told us, “It’s very short staffed. Waits for support are very long. If you ring the bell someone will come but say we can’t help as we need two staff. Sometimes [my family member] will call to go to the toilet, but it will be 45 minutes before carers come. They will have soiled themselves by then. It’s not the carers’ fault if there’s not many of them.”

Staff told us that they were over stretched and at times staffing levels were too low which meant that they were not able to meet people’s needs in a timely manner. One told us, “It’s very hard. You know you cannot do what you want to do. Feel you are doing a bad job. People deserve more than this.” Another told us, “It’s upsetting I can’t do my job properly. Things are not up to standard I know that.” The registered manager told us that they had been through a period where they had experienced a high level of staff sickness. Other staff had picked up some shifts and they had started to use agency staff, but the agency had not always been able to provide staff at short notice. The registered manager was working significant hours as a nurse but also covering other staffing shortfalls. They assured us that they had made a number of new staff appointments, who were going through the recruitment process. The registered manager acknowledged that activity staff had been redeployed to provide care but told us that they had taken a group of people on the Norfolk broads on an adapted boat and had a shopping trip planned. At the feedback meeting they told us that due to recent staff appointments the activity staff had now returned to their substantive role.

Care was largely task based, and staff did not have time to sit and chat with people. Staff were observed to be caring in their approach but busy and focused on supporting people with repositioning, assisting people with personal care and delivering drinks. Call bells sounded and often went to an emergency alarm before a member of staff was able to respond. There were no activity staff as they had been transferred over to work on care delivery to ensure peoples physical needs were met. People were observed to spend a lot of time in their room and or in bed with little to occupy them. Only a small number of people accessed the lounge and dining room at lunchtime.

People’s needs were not always met. Care records viewed and feedback we received indicated that people did not always have access to key elements of care, including meaningful leisure time, emotional support, encouragement to eat and access to regular showers. There was a dependency tool which was used to calculate how many staff were needed but we saw this did not consider the layout of the building. The systems and processes for ensuring continuity and resilience of staffing did not work effectively. We viewed recruitment records to ensure that correct and safe pre-employment checks were being undertaken prior to staff commencing work. We found that one person did not have a reference. They had not yet commenced employment, and the registered manager followed this up with the prospective employee’s last employer.

Some relatives raised some concerns about the impact of general wear and tear on the furnishings, but overall people were largely satisfied with the systems in place.

The registered manager told us that the service had a designated infection control champion who had attended additional training and promoted good infection control practice within the service. Practical training sessions on infection control were organised throughout the year and there were clear procedures in place for outbreak management. There were ongoing upgrading works which included replacing the carpet in the communal areas with a surface which was easier to maintain and keep clean.

The home was largely clean however we did note staining on the carpet and a smell of urine on the stairway. The carpet cleaner was broken, and staff were using an alternative while waiting on a replacement. Staff were observed using personal protective equipment appropriately. The laundry was clean and well organised with designated areas for the management of laundry.

Infection control audits were undertaken but the most recent audit could not be located. The registered manager told us that they had addressed the outstanding concerns.

Relatives told us that medicines were managed well, and people received their medicines when they needed them.

Staff told us that they were confident handling peoples medicines and had their competence to do so assessed regularly. The service promoted the independence of people to manage their own medicines when appropriate to do so, however, the risks around this were not always considered and recorded. Topical medicines were not being kept securely in people’s rooms putting people at risk of accessing them and causing themselves accidental harm. When people were prescribed medicines on a when required basis (PRN), for some, there was a lack of detailed written guidance for staff to refer to ensure they were given consistently and appropriately. When people were prescribed medicated skin patches there were additional records to show that the sites of application of some patches, but not all, had been appropriately varied to reduce the risks of adverse effects from them. In addition, there was a lack of records for the removal of previous patches to ensure safety. We also identified medicines risks around the use of paraffin-based topical medicines and fire at the home and asked the service to put in place appropriate risk assessments.

People received their medicines as prescribed however the service did not always have effective oversight systems in place to identify issues and ensure consistency of practice. However, once the issues were highlighted by inspectors the registered manager took action to address them.