Archived: Ashley Down Nursing Home

Ashley Down Nursing Home is a residential care home providing personal and nursing care to 10 people aged 65 and over at the time of the inspection. The service can support up to 19 people. Some people were living with dementia and people required support to move around the service.

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

People were not supported by enough staff to keep them safe and provide the support to meet their needs. The provider relied heavily on the use of agency nurses and carers. Recruitment practices were unsafe. People could not be assured the relevant checks had been carried out on potential new staff to ensure they were safe to provide their support because the provider did not carry out robust checks. Staff did not complete regular training to make sure their skills and knowledge were up to date with current legislation and best practice. There was no oversight of what training needed to be completed and when it should be completed.

People’s medicines were not managed safely. They were not always ordered on time to make sure people had their medicines when they needed them. Medicines were not disposed of safely and in line with national guidance and best practice. Medicines records were not consistently accurate and there were unexplained gaps in the records.

The premises were not always safe and essential checks, such as gas safety, had not been completed in a timely way. There had been significant concerns with the fire system when fire doors were not closing in an emergency. We contacted the local fire and rescue service who attended the service and instructed the provider to take steps to keep people safe. The service was clean; however, areas of the service had been affected by leaks and there was no maintenance plan to rectify this or redecorate the rooms.

People’s dignity was not always promoted. For example, staff did not notice when a person had large holes in their trousers. People’s privacy was respected.

There was a lack of oversight of the quality of service and there was no plan to drive improvements. Audits and checks were inconsistent and not robust. The previous six inspections identified significant concerns. The provider did not take any responsibility or ownership or give any assurances that immediate action would be taken to address CQC’s concerns at this inspection. The provider and manager did not work cohesively to implement changes and they did not lead by example.

People were supported to eat a healthy and balanced diet and were offered drinks throughout the day to keep hydrated. Meals looked appetising. People’s health care needs were assessed, monitored and reviewed. Staff referred people to the relevant health care professionals, such as specialist nurses, when required and followed advice they were given. When people were supported at the end of their life, staff worked with hospice nurses to make sure they were supported to have a comfortable, dignified and pain-free death.

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.

Relatives told us they were happy with the care their loved ones received and that the staff were kind. Staff knew people well and were knowledgeable about how people preferred to be supported. Staff understood people’s communication needs and spoke with us about how they observed people’s body language when they were unable to express themselves verbally. Information, such as the resident’s guide and statement of purpose were available in an easy to read format. When a complaint had been received, the provider had investigated and responded to the complainant in line with their policy. Complaints had been satisfactorily resolved.

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

Rating at last inspection and update

The last rating for this service was Requires Improvement (published 06 February 2019).

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations. This service has been rated Inadequate or Requires Improvement for the last six inspections.

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 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.

Ashley Down Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing and 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. Ashley Down Nursing Home provides accommodation and support for up to 19 older people. There were 13 people living at the service at the time of our inspection. People had varying care needs. Some people were living with dementia, some people had diabetes or were recovering from a stroke, people required support with their mobility around the home, no one was able to walk around independently.

Although a manager was in post, they were not 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.

At our last inspection, on 20 and 21 February 2018, the service was rated as ‘requires improvement’. At this inspection, the service continues to be rated requires improvement. Since two previous ‘inadequate’ ratings, this is the second consecutive time the service has been rated requires improvement. However, improvements have been made in many areas.

At the last inspection we found breaches of Regulations 12, 18 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to, medicines administration processes were not managed safely; robust recruitment processes were not used to make sure only suitable staff were employed; Registered nurses and staff did not receive the appropriate training to carry out their role.

The provider and registered manager sent action plans dated 27 April 2018 stating they had already made the improvements to make sure regulations 12 and 19 were met. They said they would meet regulation 18 by 18 May 2018. At this inspection, the provider and registered manager had made improvements in most areas. People’s prescribed medicines were now being managed and administered safely. Robust recruitment processes were now being followed to make sure only suitable staff were employed.

Although improvements had been made to the training of nurses and staff, there were still areas that needed to improve. The manager did not have access to staff training records and registered nurses had not completed professional development training.

Although the provider had a means of assessing people’s needs to determine the numbers of staff needed each week, staff did not always have the time available to sit and chat with people. Staff numbers at night were low, meaning there was a risk people’s needs might not be met. We have made a recommendation about this.

Although the food looked appetising and there were no complaints about food, people were not given suitable choices on the menu at meal times. Accessible formats of the menu were not available to help people to make choices. We have made a recommendation about this.

We received very positive feedback about the new manager, their knowledge and their approachability. This was their first position as a manager, having previously held the role as senior nurse at the service. The new manager had not received the support, training and access to local networks to help them to succeed in their role. We have made a recommendation about this.

Although the manager had been in post since August 2018, they had not applied to register with the Care Quality Commission. It is the provider’s legal responsibility to ensure a registered manager is in post.

Staff felt supported and confirmed they could speak with the manager at any time if they needed to. They were confident any concerns they had would be acted on quickly.

Quality audits, to monitor the safety and good quality of the service were effective in identifying where improvements were needed and action was taken to quickly remedy areas of concern.

At the last inspection, we found the support of people’s rights within the basic principles of the Mental Capacity Act 2005 needed to be improved. People’s capacity to make decisions was now appropriately assessed and any decisions were made in their best interests.

People’s privacy and dignity was not always respected at the last inspection. The provider had taken action to rectify the concern and people were now able to sit in the lounge area with their privacy respected. Many bedrooms were not made personal and homely at the last inspection. This had much improved and people had their personal belongings and mementoes around them.

People were supported to maintain their independence to help to keep them active. Relatives and friends were welcomed when visiting at any time.

Access to activities and interests was more available since the last inspection. An activities coordinator spent most of their time with people individually as this met the needs of people living in the service, although people were encouraged to join in together where they could.

The manager carried out an assessment of people’s needs before they agreed people could be admitted, to make sure nurses and staff could provide the care and support needed. Care plans were person centred and detailed the individual support people needed. People’s preferences and likes and dislikes were recorded. Risks were identified and management plans were in place to keep people safe and prevent harm.

Staff knew their responsibilities in keeping people safe from abuse. Procedures were in place for staff to follow. The provider and manager had worked with the local safeguarding teams when concerns had been raised.

Registered nurses, including the manager, were able to provide nursing care to people. Health care professionals were referred to when people needed further support with their health needs. People were supported at the end of their life and their final wishes were recorded.

The service was clean and odour free and infection control practices were being used to good effect.

All essential maintenance and servicing had been carried out at the appropriate times, including fire equipment and alarms.

The provider had displayed the ratings from the last inspection, in February 2018, in a prominent place so that people and their visitors were able to see them.

During this inspection we found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations. You can see what action we told the provider to take at the back of the full version of this report.

Ashley Down Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing and 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. Ashley Down Nursing Home provides accommodation and support for up to 19 older people. There were 11 people using the service at the time of our inspection. Some people were unable to communicate verbally with us. People had varying needs including diabetes and Parkinson's disease and some people were living with dementia. Some people required the use of a hoist to help them to move from their bed to a chair and vice versa and others required two staff to assist them to move around. Six people were cared for in bed due to their frail health.

A registered manager was in post. The registered manager was also the registered 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. A new manager was in post who had not yet registered with CQC, this manager was present throughout the inspection, providing the information we requested.

At our last inspection on 4 and 7 July 2017 we found breaches of Regulations 9, 11, 12, 17, 18, 19 and 20A of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Five breaches had continued since the previous inspection relating to, person centred care and the lack of meaningful activity to avoid social isolation; people’s basic rights and consent to care and treatment; the management of risk in relation to individuals’ safety and the safety of staff; the management of the deployment of staff to ensure safe staffing levels and the management of effective systems to ensure the quality and safety of the service. Two further breaches were identified relating to safe recruitment practices and the display of the previous inspection ratings in a prominent place. We placed the service in special measures for the second time and initiated action against the provider. This inspection took place to check that the provider had made improvements in the areas that required improvement.

At this inspection, we found the provider had made improvements within the service, although further improvements were required and work was still in progress.

We told the provider they must not admit any new people into the home following the last inspection in July 2017. This meant the provider and the new manager were able to spend time improving the quality and safety of the service for the existing people living there.

People and their relatives told us they received care that was safe, effective, caring, responsive and well led.

At this inspection, we found that sufficient improvement had not been made to the assessment used to determine the numbers of staff required to provide the level of care people needed. Staff did have the opportunity to meet with their line manager on a regular basis to discuss work related issues.

Sufficient improvement had not been made to the recruitment processes. Robust checking had not always been employed when assessing the suitability of new staff to provide care and support to people living in the service.

The evidence was not available to show that staff had received the training and updates required to carry out their role providing care and support to people. Registered nurses were not provided with the opportunities to continuously develop their skills in order to maintain and improve their professional role. New staff were not provided with the induction, training and development at the start of their employment in order to succeed in their role.

Some elements of medicines management needed improvement in order to provide a safe and effective service when administering prescribed medicines.

Improvements had been made to the safe management of individual risks to prevent harm. Record keeping had improved, staff recorded the time they spent with people and what they did so their care could be monitored. Accidents and incidents were recorded well and monitored by the manager to prevent further incidents. More detailed plans were now in place to assist people to evacuate the building or keep them safe in an emergency.

Improvements had been made to the assessment and support of people who lacked the capacity to make their own decisions, although further work was underway by the new manager to improve this area further.

Referrals to appropriate health care professionals was now better evidenced. A consistent approach was not taken when monitoring the blood sugar of people with diabetes. We have made a recommendation about this. An assessment tool used to monitor the risk of malnutrition was erroneously scored, showing a score that was not correct. We have made a recommendation about this.

The provider had not responded in a timely manner to requests from registered nurses to purchase a new camera in a timely manner to support them to evidence the progression and treatment of appropriate wound care.

Improvements had been made to the person centred approach within care planning, showing information crucial to people’s care was recorded in their care plans. Further work was needed to embed the information provided in care planning into the daily practice of the staff such as ensuring practice was not routine led. Although people were involved in decisions about their care, and told us this was the case, this was not always evidenced in the records.

People had the opportunity to discuss their wishes at the end stages of their life if they wished. People’s cultural and spiritual needs were recorded, however this needed further work to ensure it was relevant and assumptions weren’t made.

Some concerns were found around maintaining people’s privacy and dignity, however, this was not a wider issue. People and their relatives told us their privacy was respected by staff.

Although improvements had been made to the quality and safety of the service provided, further action was needed through sustained management and leadership to ensure the progress continued. Monitoring and auditing systems were now used to better effect to inform the improvements required and the action to be taken. However, the systems were still in their infancy and needed to embed to evidence they were sufficient to ensure progress could be maintained.

People and their relatives gave positive feedback about the kind and caring nature of the staff team. Staff knew people well and a friendly and more relaxed atmosphere was evident. People thought they were listened to and were involved in their care and how this was delivered.

A greater emphasis was placed on meaningful activity. People’s interests were taken into account and catered for on an individual basis. During this inspection, people were not left unattended for long periods of time.

Staff had a good understanding of their responsibilities in raising concerns of a safeguarding nature. Staff felt the management team would listen to and act on any concerns they had, however, they knew how to tell organisations outside of the service if this was necessary.

The food provided was of good quality and people were happy with the meals and menu choices. Specific dietary needs were catered for and communicated to the kitchen staff.

People and their relatives were given opportunities to give their views of the service through meetings. People told us they were listened to and their views were taken into account.

Positive feedback was extended from people, their relatives and staff about the new manager and their management and leadership skills.

The service was clean and odour free. All maintenance of the premises and servicing of equipment was undertaken when necessary by the appropriate professional bodies.

The provider had now displayed the ratings from the last inspection in July 2017 in a prominent place so that people and their visitors were able to see them.

During this inspection we found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations. You can see what action we told the provider to take at the back of the full version of this report.

This was a planned comprehensive inspection to follow up from the previous inspection report when we placed the service into special measures to monitor improvements made. The local authority had visited the service since the last inspection and had raised their concerns that improvements had not been made.

Ashley Down Nursing Home is registered to provide accommodation for older people who require nursing or personal care. The home could provide care and support for up to 19 people. There were 15 people living at the home at the time of this inspection. Two of these people were in hospital so 13 people were actually living in the home. People had complex health needs, including diabetes and stroke. Many people were living with dementia, some at an advanced stage requiring intense support from registered nurses and staff.

The registered provider of the service was also the 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. The registered manager was not available on the first day of inspection, however they were available on the second day.

Our last inspection report of this service was published on 20 February 2017 and related to an inspection that had taken place on 22 and 24 November 2016. At the inspection in November 2016 we found six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches were in relation to; Regulation 9, people’s individual needs were not adequately assessed and regular checks on people were not recorded; Regulation 11, people’s care plans did not reflect their basic rights to consent and decision making; Regulation 12, evidence was not available to show that care was provided in a safe way; Regulation 16, the correct information was not available through an up to date procedure to enable people to make a complaint; Regulation 17, effective systems were not in place to monitor the quality and safety of the service and Regulation 18, staffing levels were not based on peoples’ individually assessed needs. We also found a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009, CQC had not been notified of important events that had taken place in the service.

We asked the provider to take action to meet regulations 9, 11 and 16. We also asked the provider to take action to meet Regulation 18 of the Care Quality Commission (Registration) Regulations 2009. We took enforcement action against the provider and told them to meet Regulation 12 by 30 March 2017, Regulation 17 by 28 April 2017 and Regulation 18 by 31 January 2017.

The provider sent us a report of the actions they were taking to comply with Regulations 9, 11 and 16 and they told us they would be meeting these Regulations by 28 February 2017. They also said they would meet Regulation 18 of the Care Quality Commission (Registration) Regulations 2009 by 28 February 2017.

At this inspection we found the provider and registered manager had made some improvements to the service and standard of care. The provider had a new complaints procedure in place and regular checks on people were now recorded. The provider had notified CQC of important events as required. The improvements related to Regulation 16 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and Regulation 18 of the Care Quality Commission (Registration) Regulations 2009. However many improvements had not been made and we found continuing breaches of regulations from the last inspection. These related to Regulation 9, 11, 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also found new breaches of Regulation 19, safe recruitment processes were not in place to make sure only suitable staff were employed to work with people and 20A, the ratings of the previous inspection had not been displayed as required, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Risk assessments around people’s personal and nursing care needs were in place. However, important and serious individual risks had not been identified and risk assessments had not been undertaken to control and minimise those risks to keep people and staff safe. Staff had not had the necessary training to keep people and themselves safe and safety had been compromised.

The premises were clean and suitably maintained and equipment and utilities had been serviced. However, fire evacuation guidance did not give the specific information required to keep people safe. Fire evacuation practice drills had not been carried out to ensure people and staff knew what to do in the event of a fire.

Staff had not been sufficiently deployed to ensure peoples’ social and welfare needs were met. People were often left sitting on their own in the lounge or in their bedroom with little stimulation. People were not engaged in meaningful activities that were based on their interests and to create a motivating environment.

People’s care plans were suitable for their personal care and nursing needs. However, care plans were not person centred and there was no focus on people’s well-being, social and cultural needs based on their preferences and interests. People and their relatives were not involved in reviewing their care plans.

Mental capacity assessments that had been undertaken were not appropriate for the decisions being made. Consent forms had been signed inappropriately on people’s behalf. Where decisions had been made on people’s behalf, a best interests process had not been followed as determined within the Mental Capacity Act 2005. Deprivation of Liberty Safeguards (DoLS) applications had been made to the local supervising authority.

The provider had asked for feedback of the service from people and relatives. There was no evidence that the comments made had been listened to and actioned.

Although an audit and monitoring system was in place it was not used effectively to identify concerns and act on them to drive improvements within the home.

Some staff thought the provider was approachable and others thought they did not listen to their views and concerns.

New staff had not had the appropriate checks made of their suitability to care for and support the people living in the home.

The provider had not displayed the ratings of the previous inspection in a prominent place as required by the regulations.

Although an up to date complaints policy was in place, the complaints process outlined within the service user guide did not reflect this. We have made a recommendation about this.

People received their prescribed medicines by registered nurses. The medicines administration process was managed well, including the ordering, storage and return of medicines in the home.

Staff had a safeguarding procedure to access the information they needed to protect people and raise concerns. A copy of the local authority procedure with their full guidance for reporting concerns was kept in the home, however, it was an old copy with the wrong information available. We have made a recommendation about this.

Staff had one to one supervision meetings to support their development. Mandatory training and updates had been undertaken since the last inspection. Some training requested by registered nurses for the benefit of their professional development and for the benefit of people living in the home had not been carried out. We have made a recommendation about this.

People said they were happy with the food provided. Where people required a special diet or consistency of food this was documented and appropriate advice and guidance had been sought.

People’s health needs were generally taken care of by the registered nurses working in the home and GP practices. Health referrals had been made, however not always suitably quickly and not always pursued and followed up.

Staff had a kind and caring approach to people and made sure they knocked on people’s doors before entering their room.

We found seven 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 the report.

The overall rating for this service is ‘Inadequate’ and the service therefore remains in ‘special measures’.

At the last comprehensive inspection this provider was placed into special measures by CQC. This inspection found that there was not enough improvement to take the provider out of special measures.

CQC is now considering the appropriate regulatory response to resolve the problems we found.

Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

We inspected Ashley Down Nursing Home on the 22 and 24 November 2016 and the inspection was unannounced. Ashley Down Nursing Home provides accommodation for up to 19 people over the age of 65 that may require nursing and personal care and support, some of whom living with dementia or a physical disability. The accommodation is provided in an older style detached house in a residential street. There is a communal lounge, dining room, kitchen, communal bathrooms and bedrooms with en-suite bathrooms. Outside there is a good size garden that people have access to. There were 16 people living in the home on the days of our inspection.

The provider was also the registered manager, who was in day to day charge of the home. 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 undertaken on the 07 January 2016, we identified breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014 in relation to staffing levels; recruitment practice, the provision of meaningful activities, management of complaints, notifying CQC of significant events and improving their quality assurance framework. The provider sent us an action plan stating they would have addressed all of these concerns by June 2016. At this inspection we found the provider had made improvements to safe recruitment practice but the provider continued to breach the regulations relating to the other areas.

Systems in place to assess the quality of the service provided were not always effective and had not consistently identified shortfalls in the provision of care and quality. Care plans were not consistently fit for purpose and lacked personal information on people’s likes, dislikes and what was important to them.

The principles of the Mental Capacity Act (MCA 2005) were not embedded into practice. Appropriate processes in regard to mental capacity assessments had not been followed for the use of potentially restrictive care practices such as bed rails and wheelchair lap belts.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. DoLS applications had been made to the local authority and had been approved. However the registered manager had continued to fail to notify CQC of the authorisations. DoLS care plans were not in place.

The risk of social isolation had not been addressed or mitigated. People had no access to stimulation or meaningful activities. Insufficient staffing levels and deployment of staff meant staff had no time to provide activities or one to one chats with people. A visiting relative told us, “ I have no complaint apart from the fact there is little to do but I understand they are recruiting; you’d think they would think of something in the meantime though, it doesn’t take much to start a sing-along for example. I guess they are too busy to do that, they have so much to do.”

The management of continence required improvement. Large gaps in documentation reflected that people could go up to seven hours without support to meet their continence needs. Staff told us they received essential training that equipped them with the skills to meet people’s individual care needs. The provider had failed to identify that training had not been provided on the safe and effective management of diabetes, epilepsy and pressure care. We have identified this as an area of practice that needs improvement and have made a recommendation about reviewing the formal provision of training based on best practice guidelines and people’s individual care needs.

The risk of skin breakdown for people had been assessed, however, where people received care on an air mattress, documentation failed to record that the setting was regularly checked. We have identified this as an area of practice that needs improvement and have made a recommendation about the monitoring and oversight of air mattresses.

Where people had lost weight or their blood sugar level had not been monitored, documentation did not consistently reflect what action had been taken and why. A complaints policy was in place but the provider had failed to update and review the policy since the last inspection in January 2016 when it was identified the policy was not fit for purpose. The management of risk across the home was not consistent and risks to people's safety had not consistently been mitigated.

Risks associated with the environment were not consistently up to date. The provider operated a stay put policy in the event of a fire. For people living on the first floor of the home, in the event of a fire, they would be unable to be evacuated as evacuation chairs were not in situ. We have made a recommendation about the review of their internal fire risk assessment and procedures.

People were supported to receive their medicines on time by qualified and competent staff. Medicines were managed and stored appropriately. People were supported to access health services and their health care needs were being met. People were safe and staff knew what actions to take to protect them from abuse.

Staff treated people with kindness and compassion. One staff member told us, “The residents are wonderful.” People spoke highly of the food provided and where people required one to one support with eating and drinking, this was provided in a kind and gentle manner.

Training schedules confirmed staff had received safeguarding training and demonstrated a firm awareness of the actions to take to people safe from harm or abuse. Recruitment practice was safe. Risks associated with the environment were managed and the provider was making arrangement to make the environment more dementia-friendly.

The overall rating for this service is 'Inadequate' and the service is therefore 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 sufficient improvement is not made within this timeframe so that 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 so 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.

During our inspection we found a number breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Below is a summary of what we found. The summary is based on our observations during the inspection, discussions with people using the service, their relatives, the staff supporting them and looking at records.

If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

We found that people were not always safe due to poor security at the home. This was because one of the fire doors at the side of the building was broken and it was possible to access the home. We also saw that a side door in the living room was open during our visit of 22 April 2014 and it was possible for people to walk in and out of the home. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to ensuring appropriate measures are taken in relation to the security of the premises.

We reviewed the arrangements in place in case of fire and found that evacuation plans were not in place or known to staff. We asked staff if they were aware of personal emergency evacuation plans that would include information about how to safely evacuate people living at the home. They did not know if plans were in place. This meant that people may be at risk of harm in the event of a fire.

Is the service caring?

People we spoke with were positive about the support given to them by members of the staff team. We saw that staff were attentive and caring. However, we observed that people sometimes had to wait for their needs to be met as staff were busy providing support for other people. We have asked the provider to tell us what improvements they will make in relation to ensuring that there are sufficient numbers of suitably qualified, skilled and experienced staff.

Is the service effective?

We found that people's needs had been assessed before they moved into the home and detailed care plans had been developed that included information about medical needs and particular risks that had been identified. However, people we spoke with told us they were not involved in their care planning. Two relatives told us they had not been asked for their views concerning what should be included in the care plan for their family member. We were told there was no service user guide in place or information that was given to people when they moved into the home. This meant that people had not been consulted and their views had not been taken into account concerning how they wanted their care delivered. We have asked the provider to tell us what improvements they will make to ensure people are involved in their care.

Is the service responsive?

We saw that although there was a file kept concerning complaints people had made there was no indication concerning whether or not complaints had been investigated or the response given by the provider. People we spoke with did not know about a complaints system and we did not see any information displayed in the home. Staff we spoke with were not aware of any information that had been given to people concerning how to raise concerns. They were also unaware that the home kept a log of complaints. We have asked the provider to tell us what improvements they will make to ensure people are aware of the complaints procedure at the home and records are kept concerning the outcome of complaints.

Is the service well led?

We were not able to see any evidence that quality control audits or other systems were in place to assess the quality of the service. People told us they were not asked for their views concerning the care they received. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to quality assurance, and the improvements they will make in relation to ensuring the people are aware of the complaints procedure in order to raise concerns.

We carried out this inspection to follow up on concerns identified during our inspection of 01 October 2013. We found that some steps had been taken to address the concerns which had been raised. However, we identified a number of ongoing concerns such as the security of the premises. This meant that people's safety was not protected and the provider was not learning from incidents.

During our inspection of 01 October 2013 we identified that many records relating to the management of the home could not be located promptly when required as the provider was away and many of the records were kept in their office. They wrote to us on 18 December 2013 and stated that all records apart from staff files were kept in the nurse's office. However, during our inspection of 22 April 2014 we found that a number of records could not be located promptly as the provider unavailable.

On 27 January 2014 we served a fixed penalty notice to Ashley Down Nursing Home Limited for failing to have a registered manager in place at Ashley Down Nursing Home. A fine of '4,000 was paid.

At the time of our inspection on 22 April 2014 the home did not have a registered manager in post but the provider had indicated that they wished to undertake this role in the future.

We looked at care plans and found that these contained information staff would need to know to be able to support a person's needs. There were assessments undertaken on admission and the care plans had been developed and drawn up with the individual, where possible, and their family had been consulted on aspects of the care plan.

We saw that people who used wheelchairs or who needed support to get to the dining room were left in the dining room for 45 minutes after they had finished their meals. We heard people calling for staff to take them out of the dining area and when we entered the room people were complaining about being left for so long and asking for our assistance to get staff to come. One person said, 'We wait too long in the dining room' This meant that the registered person was not respecting people's dignity.

We talked with people who used the service or their relatives, one person said 'staff treat me with respect, I get on very well with staff' another said 'I like my room and the staff are lovely'.

We found that the registered person was not following procedures required under the Mental Capacity Act 2005 about how to make decisions for the person when there was a lack of capacity.

We talked with people who used the service or their relatives. Two people told us that there was a smell of urine in the home; one person told us that staff are often cleaning the carpets.

People told us that the food was nice and that the staff were pleasant.

We found that there were no procedures in place, available or known to staff to deal with foreseeable emergencies.

We found that the registered person was not making suitable arrangements to ensure that people who used the service were safeguarded from abuse.

We found that people who used the service, staff and visitors were not always protected against the risks of unsafe or unsuitable premises.

We talked with people who used the service or their relatives and we were told by three people that there were not always enough staff at the home. One person told us that they do not always get two staff to carry out manual handling operations when this is a requirement in their care plan.

We found that records were not accessible and that we could not check to see if the registered person was managing the delivery of the regulated activity safely.