The Grange Residential Care Home

The Grange Residential Care Home is a residential care home providing accommodation for people requiring personal care to up to 36 people. The service provides support to younger adults and older people, people living with dementia, people with a sensory impairment and people with a physical disability. At the time of our inspection there were 36 people using the service. The accommodation contains several communal areas on the ground floor and has bedrooms, bathrooms and toilets on both floors.

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

We found people were at risk of harm as fire safety risks and risks associated with substances posing a hazard to health had not always been identified. Infection prevention and control measures (IPC) were not consistent in the home to keep people safe from the risk of cross infection.

Systems to identify improvements in the home were not implemented effectively. Audits carried out by the manager and provider did not identify the fire safety and IPC issues we identified.

People felt safe in the home and they, or their relatives, knew how to raise any issues they might have. There were sufficient staff deployed to meet people’s needs. Medicines were managed safely, and people received their medicines as prescribed.

People’s needs were assessed, and their care planned in line with current good practice guidelines. People were referred for professional assessment and care when needed. People were cared for by competent staff.

People were supported by staff who were kind and knew them well. Staff understood and respected people’s individual preferences.

People, or their relative where appropriate, were involved in their own care. Care plans were person centred, including details of people’s sensory and communication needs. People, or their relative, felt confident any complaints they may have would be dealt with.

People believed the service was well led and gave positive feedback about the registered manager and staff team. The overall aim of the service was for people and their families to be happy. This outcome was worked towards by the care staff to achieve this for the people who lived there. Staff felt well supported in their role.

Mental Capacity Act

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.

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 20 January 2021).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection. We have found evidence that the provider needs to make improvements. Please see the safe and well led sections of this full report. You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed. We have identified breaches in relation to the identification and safe management of fire safety risks, the control of substances hazardous to health and infection prevention and control at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The Grange is a residential care home providing personal care to 27 people at the time of the inspection, some of whom were living with dementia. The service can support up to 34 people over two floors. The accommodation contains several communal areas and has bedrooms, bathrooms and toilets on both floors.

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

The service was inspected during the COVID-19 pandemic. The service has systems for sharing and cascading up to date guidance and best practice to all staff. However, the registered manager did not always keep an ongoing record of policy and procedure updates to evidence that best practice information had been shared to keep people safe. We have made a recommendation that the provider reviews relevant guidance, updates policies and ensures this information is cascaded.

There were sufficient staff to support people's needs and they had been safely recruited. People we spoke with told us they were happy with the level of staff and we saw this during the inspection.

Staff received safeguarding training and had a good understanding of the principals involved in acting when abuse was suspected. Staff also completed the provider’s mandatory training and annual updates to ensure that their knowledge and skills were up to date.

People told us that they were cared for and felt safe in the home. Their needs were understood through assessments and support plans. We saw that people were involved in their care planning. Staff had good knowledge and skills and this ensured people's needs were met.

People received care that was person centred. People had maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People told us staff were kind and caring, this was observed during the inspection. People said that they could raise issues with staff and the management team.

Medicines were managed and administered safely and this meant that people received their medicines as prescribed by healthcare professionals.

Staff reported and recorded incidents appropriately. Managers responded to incidents to achieve satisfactory outcomes as well as learning and improvement.

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 9 October 2019).

Why we inspected

The inspection was triggered due to a confirmed COVID-19 outbreak. We undertook a review of Infection Prevention and Control (IPC) practices to assess whether the service was compliant with IPC measures. This took place on 13 November 2020 and was unannounced.

During the targeted inspection a number of concerns were found around infection control and governance. These concerns prompted a second day of inspection. We undertook a focused inspection on 2 December 2020 to review the key questions of Safe 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.

The overall rating for the service remains Good, this is based on the findings at this inspection.

We found no evidence during this inspection that people were at risk of harm from this concern. Please see the Safe and Well-led sections of this full report.

Follow up

We will continue to review information we receive about the service until we return to visit as part of our reinspection programme. If any concerning information is received we may inspect sooner.

The Grange Residential Care Home is a care home that was providing personal and nursing care to 33 people aged 65 and over at the time of the inspection. The service can support up to 36 people. The home accommodates people across two separate floors, each of which has separate adapted facilities and a lift. Some of the people living in the home had a diagnosis of early stage dementia. The home is situated in the village of Sandiacre in Nottinghamshire.

People's experience of using this service and what we found:

The provider had a system to ensure staff documented any accidents or incidents which had taken place. However, sometimes it was not clear what action the registered manager had taken on some of these instances. In addition, the registered manager had not informed CQC of two important incidents as required under current regulations. We have made a recommendations about this that can be seen in the 'Well-led' section of this report.

Staff told us they received good support from senior staff and the registered and deputy manager. We did note that most of the checks and audits at the home were completed by the registered and deputy managers and had not been effective in identifying the issues found during this inspection. There was an absence of documented input of any checks by the provider. We have made a recommendation about this that can be seen in the 'Well-led' section of this report.

People told us they were well cared for and felt safe in the home. We found staff had been safely recruited. In addition, they had completed the provider’s mandatory training and annual updates to ensure their knowledge and skills were up to date.

People were happy with the level of staff in the home and we observed a good staff presence at the inspection.

Staff received safeguarding training and had a good understanding of the principals involved in acting when abuse was suspected.

Medicines were managed and administered safely and this meant that people received their medicines as prescribed by healthcare professionals.

People's needs were met through assessments and support planning. The service worked well with healthcare and social professionals to achieve positive outcomes for people. Staff had good knowledge and skills and this ensured people's needs were met.

We saw good examples of when people had been supported to maintain a healthy and balanced diet.

People told us carers and staff were compassionate and kind and during the inspection, we observed this to be the case. Management and staff knew people well. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People received care and support that was person-centred. We saw examples of how the care and support people received enriched their lives through meaningful activities. The service had a robust complaints policy and people said that they could raise issues with staff and the management team.

The values and culture embedded in the service ensured people were safe and at the heart of the care and support they received. The registered manager and deputy manager planned and promoted holistic, person-centred, high-quality care resulting in good outcomes for people. People knew how to feedback their experiences and this was considered and acted upon by the registered manager.

There was an end of life policy in place that could be used if appropriate. Staff members had been trained around this and were able to ensure best practice was applied during times when people were at the end of life.

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 25 April 2017).

Why we inspected:

This was a planned inspection based on the previous rating of the service.

Follow up:

We will continue to review information we receive about the service until we return to visit as part of our re-inspection programme. If any concerning information is received we may inspect sooner.

This inspection visit was unannounced and took place on 8 March 2017. At our last inspection visit in May 2016 we asked the provider to make improvements to the assessments they completed when people did not have the capacity to make decisions. The provider sent us an action plan in June 2016 explaining the actions they would take to make improvements. At this inspection, we found improvements had been made. The service was registered to provide accommodation for up to 34 people. People who used the service had physical health needs and/or were living with dementia. At the time of our inspection 32 people were using the service.

There was a registered manager 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 2008 and associated Regulations about how the service is run.

People were supported to make choices and when required assessments had reflected the person’s capacity. Best interest assessments where then completed to ensure the decision was made in conjunction with the relevant people. The home had enough staff to support people’s needs. The staff employed had received a range of checks to ensure they were suitable to work in the home. The manager and provider had established a range of audits to support the improvements within the home. We saw feedback was sought from people and relatives and any areas raised had been considered and responded to.

People told us they had established positive relationships with staff who showed respect for them. People were able to choose the meals they wish to eat and special diets had been catered for to ensure people received the correct support for their nutritional needs. We saw that medicines were managed safely and administered in line with people’s prescriptions. Referrals had been made to health care professionals and any guidance provided had been followed.

Care plans provided details about the person’s life, preferences and how they wished to receive their care. People were encouraged and supported with activities they wished to engage in. There was a complaints policy which was available, however no one had felt the need to raise any concerns.

Staff felt supported by the manager and there was a clear process in place to cascade information about the service and the needs of people. Staff had received training and the manager was planning to invest in further training to expand the staff knowledge in supporting people that were living with dementia.

We saw that the previous rating was displayed in the reception of the home as required. The manager understood their responsibility of registration with us and notified us of important events that occurred at the service; this meant we could check appropriate action had been taken.

There was a registered manager 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 2008 and associated Regulations about how the service is run.

The registered manager did not understand their responsibility to comply with the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). We were told some people lacked capacity in certain areas but capacity assessments had not been completed to show how people were supported to make those decisions.

Staff understood what constituted abuse or poor practice. There were systems and processes in place to protect people from the risk of harm. The provider determined the staffing levels based on people’s needs and the level of support they required. Medicines were managed safely and in accordance with good practice.

Staff received training to meet the needs of people living in the home and this was ongoing. Staff received training and support from experience staff as part of their induction in to the home.

People received food and drink that met their nutritional needs and were referred to other healthcare professionals to maintain their health and wellbeing.

Staff were caring in their approach, and offered support with aspects of people’s needs. Staff we spoke with had a good understanding of people’s support needs, and their previous life before coming to the home. People told us their dignity was respected.

Staff told us they felt supported and they received regular supervision, which enable them to identified areas of development or support. People felt confident they could raise any concerns with the registered manager and that they would be addressed.

There were processes in place for people to express their views and opinions about the home and we saw that their views and had been listen to and acted upon.

The home completed audits across all areas of the home and used these to reflect any trends or areas where improvements could be made. The provider worked towards awards to reflect good practice.

We found 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.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask. This is a summary of what we found:

Is the service safe?

People told us that they felt safe living at The Grange and that they were treated well. One person explained: 'The staff are lovely, I feel perfectly safe with them.' Another person told us: 'I feel safe here, the manager is lovely and they have been very good to me.'

Risk assessments were in place. Those checked on the day of our visit showed us that the risks associated with people's care had been assessed and measures had been put into place to reduce that risk. This showed us that people's health and welfare was, wherever possible, protected.

Records kept to monitor how much food and drink people had taken during each day were up to date and repositioning charts (used for people unable to move themselves in bed) showed us that people were being assisted appropriately. This showed us that people were protected from the risk of malnutrition and the development of pressure sores.

Staff knew what to do if they suspected that someone was being abused. One staff member explained: 'I would tell the manager straight the way, you can go to her with anything and everything.' Another staff member told us: 'I would tell the manager, the residents always come first.'

People who used the service told us that there were enough staff on duty and their care and support needs were always met. One person explained: 'I cannot praise them [the staff] enough for their help, I've become friends with them all.' Another person told us: 'They are always there when you need them.'

Is the service effective?

We spoke with people who used the service and they told us that they were satisfied with the care and support they received. One person told us: 'The care is excellent.' Another person explained: 'I don't want a fuss and they respect that, they don't fuss me.'

Care plans provided staff with information about people's care and support needs. It was clear from our observations and from speaking with staff, that they understood the needs of the people they supported. One person told us: 'I wear what I want and it's written down what time I get up, I can't lie in bed and they know that.'

Is the service caring?

We observed staff going about their work. They treated the people they were supporting in a kind and caring way. They provided them with the time that they needed in order to carry out a task, whether that was assisting them with their meals or assisting them to use the bathroom.

Everyone spoken with told us that the staff were caring and thoughtful. One person told us: 'I am blind and the staff always explain to me what they are doing, I am very satisfied.'

Is the service responsive?

Relevant professionals had been involved in people's care. Records showed that visits had been arranged when someone needed to be seen by their doctor or by a district nurse. Other professionals involved in peoples care included opticians and dentists. Where a person had been identified as losing weight, the local dietician had been involved in their care. This ensured that the people who used the service received the care and treatment they needed.

A complaints policy was available. This was accessible to both the people who used the service and their visitors. A copy of the complaints policy was displayed in the reception area and a copy was kept in each person's room. This enabled people to know their rights and show them how to make a complaint if they wished to do so. People told us that they knew who to talk to if they had a concern of any kind. One person told us: 'I would talk to the manager, I can talk to her, she is very helpful.'

Is the service well-led?

An appropriate monitoring system was in place. This enabled the manager to regularly monitor and assess the service and ensure that people received the best service possible.

Staff had a good understanding of their roles within the service. They felt supported by the manager and they told us that they could to talk to her, if they had a concern of any kind. One staff member explained: 'You can go to the manager, her door is always open.'

Regular meetings had taken place. Both for the people who used the service and the staff who worked there. This provided people with the opportunity to be involved in the service and have a say on how it was run.

Comments from people receiving care included, 'help is available at night. All the care workers are very good. I do not think the waiting times are unusual. I am very happy here. I have my say and I am listened to'.

'I sometimes have to wait at night but they usually get me to the toilet in time. It seems better'.

'I am well cared for by all care workers. The girls do a wonderful job and I could not ask for more'.

People's comments about care and welfare were mostly positive. Some people told us their needs were not always being met in a timely way. Comments included, 'Staff are very good and very caring, I could not ask for nicer staff'. 'Sometimes waiting for help seems a little long. When they come to you they are always really kind and helpful'. 'Sometimes I worry they may not come in time'. If people have to wait for help, this could reduce their dignity. This could mean their personal care needs may not be met on time.

People told us the food was nice and they were able to sit with their friends. We saw the food was presented in an appetising way.

We observed care workers using health care equipment. We saw people's personal aids were well maintained. We saw efforts were made to provide sufficient equipment to support both staff and people using the service. This meant each person had the necessary aid to improve their quality of life.

Three people told us they would be supported by staff or by relative's, to make a complaint if they needed to do so.

Seven people told us they were able to get up and go to bed when they wished, eat what they wanted and engage in activities if they wanted. All the people we spoke with told us their values and beliefs were respected, for instance one person told us they enjoyed the opportunity of joining in church services.

Comments on care and the atmosphere of the home included; 'it's a lovely place to live. I'm very lucky', 'the people here are the best thing about the place', 'there's always good company here.'

We observed a lunch time meal during the visit. Three people told us there were long waiting times during meal times. One person told us, 'there is a lot of waiting from one thing to another.'

We observed people receiving their medications during a meal time. The care worker administered medications to people safely and appropriately.

Comments about staff included; 'they (carer workers) will always help you. They're really good', 'you can't fault the staff', 'they (all staff) are very obliging and helpful'.

We saw that both staff and people's care records were locked away and accessible when needed.