Archived: The Granary

The Granary is a residential care service that is registered to provide accommodation, nursing and personal care for people with learning disabilities or autistic spectrum disorder, physical disabilities, and a range of neurological conditions and/or acquired brain injury. The service was registered for the support of up to 41 people. At the time of the inspection 15 people were using the service.

The service consisted of four separate lodges within one building. Each person had their own bedroom and en-suite bathroom. There were shared living and eating areas in each lodge. At the time of the inspection, there were six people living in one lodge and nine people in another. The other two lodges were not in use.

The Granary is owned and operated by the provider Sussex Healthcare. Services operated by Sussex Healthcare have been subject to a period of increased monitoring and support by local authority commissioners. Due to concerns raised about the provider, Sussex Healthcare is currently subject to a police investigation. The investigation is on-going, and no conclusions have yet been reached.

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

There was unsafe assessment, monitoring and management of risk for people with support needs regarding constipation, behaviours that may challenge, mental health, choking and breathing.

Risks around people’s deteriorating health and well-being were inconsistently managed and monitored by staff. Lessons were not always learnt, and actions not taken to investigate safety incidents, and prevent them re-occurring.

Service management, and the provider’s wider quality assurance and governance systems, had not always ensured actions were taken to address any issues and risks in a timely manner. People’s care records were not always up to date or accurate.

The provider had failed to act upon known areas of concern, non-compliance, and risk to improve the quality of care for people at The Granary. This had exposed people to on-going poor care and risk of avoidable harm.

The provider had acted to manage infection risks during the Covid-19 pandemic. Additional infection prevention and control measures in line with Department of Health and Social care guidelines had been put in place to ensure people’s safety.

We observed the service was clean and staff had access to and wore appropriate personal protective equipment. Relatives told us the service was always clean and well maintained whenever they had visited, or from what they had seen on video calls.

There were systems in place to protect people from abuse and improper treatment. A relative said they had “No doubts” their family member was at very low risk of abuse at this service. Medicines were ordered, transported, stored and disposed of safely. There was a high ratio of staff supporting people during the inspection. Staff and people said there were currently enough staff. One person said, “We have more full-time staff so no more agencies which is good I suppose.”

Staff were offered training in relevant subjects and received the registered manager and clinical leads had recently introduced additional knowledge checks and practical training scenarios in high risk areas of practice to help embed learning from training.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right Support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

This service was not able to demonstrate how they were meeting some of the underpinning principles of Right support, right care, right culture.

Right support:

The model of care and setting did not maximise people’s choice, control and

independence.

The service was in private grounds in the countryside. Opportunities for people to access the local community were limited.

The service is bigger than most domestic style properties. There were identifying signs on the road before the service’s private drive, the service grounds and on the exterior of the service to indicate it was a care home.

Right care:

Care was not always person-centred or promoted people’s dignity, privacy and human rights.

People were not always supported safely.

Staff did not always respond in a compassionate or appropriate way when people experienced pain or distress.

Right culture:

The provider’s senior management team had recently been re-structured. We were told there was a strong commitment from the new leadership team to create a culture of good quality, personalised and respectful support that involved people using their services.

The provider and the registered manager had recently begun to support staff to reflect and share ideas about improving culture and the quality of the care being provided at the service. Staff supporting people with learning disabilities did not wear uniforms or name badges when they were coming or going with people.

However, work was still needed to embed necessary changes to the existing culture, ethos, attitude and practice of staff at The Granary in order to achieve this vision.

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 20 November 2019). There was a breach of Regulation 17 Good Governance. 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 sustained and the provider was still in breach of regulations.

Why we inspected

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.

We carried out an unannounced comprehensive inspection of this service on 30 September 2019. A breach of legal requirements was found. The provider completed an action plan after the last inspection to show what they would do and by when to improve Good Governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from Requires Improvement to Inadequate. This is based on the findings at this inspection.

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

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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to Regulation 12 Safe care and treatment and Regulation 17 Good Governance at this inspection.

On 29 July 2021 we imposed conditions on the provider’s registration telling them how they must act to address serious concerns regarding unsafe care for people with known risks associated with their support needs regarding choking and/or aspiration, constipation, respiration, monitoring and managing service users’ healthcare needs, including use of RESTORE2 and behaviours that may challenge at the Granary

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.

The Granary provides nursing and personal care for up to 41 people living with physical disabilities, learning disability and a range of neurological conditions and/or acquired brain injury. At the time of our inspection, four people were living at the service. The service is located in a rural setting and is purpose built to accommodate the needs of people with complex disabilities and neurological conditions. Accommodation is provided on one level and split into four separate homes. Each home had communal areas include a lounge and dining room, with access to gardens and grounds. On the day of the inspection, only one home was in use.

The Granary is owned and operated by the provider Sussex Healthcare. Services operated by Sussex Healthcare have been subject to a period of increased monitoring and support by local authority commissioners. Due to concerns raised about the provider, Sussex Healthcare is currently subject to a police investigation, the investigation is on-going, and no conclusions have yet been reached.

The Granary had been built and registered before the CQC policy for providers of learning disability or autism services 'Registering the Right Support' (RRS) had been published. The guidance and values included in the RRS policy advocate choice and promotion of independence and inclusion, so people using learning disability or autism services can live as ordinary a life as any other citizen.

The Granary requires further development to be able to deliver support for people that is consistent with the values that underpin RRS. For example, the care planning process did not always consider people's goals or aspirations.

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

The provision of activities required further work. Activities were not consistently evaluated and assessed to consider if they were meeting people’s needs. People were not supported to regain life skills or set goals and aspirations. The care planning process required further work to ensure people’s emotional, sexuality and spirituality care needs were being met.

Links and engagement with the local community required strengthening and further work was required to ensure people were involved in the shaping and running of the service. We have made a recommendation for improvement.

Quality assurance frameworks were in place and staff spoke highly of the registered manager. Further work was required to ensure accurate documentation was maintained. Staff commented that they felt valued and respected. Staff spoke highly of communication within the service and feedback from healthcare professionals demonstrated that the registered manager was proactive and keen to improve service delivery.

Relatives told us that their loved ones were safe at the Granary. Staff had received training on safeguarding adults and understood their roles and responsibilities to safeguard people from harm or abuse. The registered manager worked in partnership with healthcare professionals and learning was derived from incident, accidents and safeguarding concerns.

People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible and the policies and systems in the service supported this practice. People were supported to access the local community and staff demonstrated warmth and kindness to the people they supported. Laughter was heard throughout the inspection and people responded to staff with smiles. Staff had built positive rapport with people and their relatives. One relative commented that staff always made them a cup of tea and provided a hug when needed.

Staff felt supported and had access to a range of training. People's nutritional needs were met, and people spoke highly of the food provided. Risks associated with epilepsy, catheter care, constipation and dehydration were managed well. People had ongoing access to healthcare professionals and staff recognised and responded well to signs that a person's health might be deteriorating.

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 the service was Inadequate (report published 1 August 2019). The provider was found to be in breach of Regulation 11 – Need for Consent, Regulation 12 – Safe Care and Treatment, Regulation 18 – Staffing and Regulation 17 – Good Governance. Conditions were imposed on the provider’s registration which required them to submit monthly reports to CQC regarding the quality of care provided at the Granary.

This service has been in Special Measures since February 2019. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This was a planned inspection based on the previous rating. We identified one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Enforcement:

We imposed conditions on the provider's registration in December 2018. The conditions are therefore imposed at each service operated by the provider, including The Granary. CQC imposed the conditions due to repeated and significant concerns about the quality and safety of care at a number of services operated by the provider. The conditions mean that the provider must send to the CQC, monthly information about incidents and accidents, unplanned hospital admissions and staffing. We will use this information to help us review and monitor the provider's services and actions to improve, and to inform our inspections.

Please see other 'actions we have told the provider to take' section towards the end of the report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality. We will also meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority and care commissioners to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Services operated by the provider had been subject to a period of increased monitoring and support by commissioners. As a result of concerns raised, the provider is currently subject to a police investigation. The investigation is on-going and no conclusions have been reached. We used the information of concern raised by partner agencies to plan what areas we would inspect and to judge the safety and quality of the service at the time of the inspection. Between May 2017 and February 2019, we have inspected a number of Sussex Health Care locations in relation to concerns about variation in quality and safety across their services and have reported on what we found.

This inspection took place due to information shared with CQC about concerns around the management of people's care needs. However, this inspection did not examine the specifics of those incidents and focused on what the care experience was for all people living at The Granary. At the inspection we rated the Key Questions ‘Safe’, ‘Effective’ and ‘Well-led’.

No risks, concerns or significant improvement were identified in the remaining Key Questions through our ongoing monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

The Granary is a care home that provides nursing and residential care. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided and both were looked at during this inspection.

The Granary provides nursing and personal care for up to 41 people who may have learning disabilities, acquired brain injury and other neurological conditions. Most people had complex mobility and communication needs. At the time of our inspection there were six people living at The Granary and one person receiving short term care. The Granary provides accommodation across four ground floor units: Walnut, Pine, Yew and Alder. Each unit has a separate living room, dining room and kitchenette. At the time of this inspection, people were accommodated in Walnut and Alder, the other two units, which could accommodate 10 people each, were unoccupied. Rooms were of single occupancy and had en-suite facilities.

There was no registered manager at the time of this inspection. The service is required by a condition of its registration to have a registered manager. A registered manager is a person who 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 had been employed since December 2018 and had applied to become the registered manager.

The Granary has not been operated and developed in line with all the values that underpin the Registering the Right Support and other best practice guidance. The Granary was designed, built and registered before this guidance was published. However, the provider has not developed or adapted The Granary in response to changes in best practice guidance. Had the provider applied to register The Granary today, the application would be unlikely to be granted. The model and scale of care provided is not in keeping with the cultural and professional changes to how services for people with a learning disability should be operated to meet their needs. People with learning disabilities using the service should be able to live as ordinary a life as any citizen.

At the last inspection in September 2018, the service was found to be in breach of legal requirements and was given a rating of 'Requires Improvement'. The provider wrote to us after the inspection to inform us about the actions they were taking.

At this inspection we found that the quality and safety of care provided to people had deteriorated. We identified gaps in how the provider was managing risks on behalf of people. Care records did not consistently demonstrate people’s care needs were being met. This included gaps in the management of epilepsy, hydration, weight loss and fire evacuation.

We found gaps in guidance and essential training to enable staff to support people who may display behaviours which challenge others safely and effectively. This was for both permanent and agency staff.

The provider was not consistently applying the principles of the Mental Capacity Act. We found conditions on one person’s Deprivation of Liberty Safeguards was not being met.

Systems to assess and monitor the service were in place but these were not sufficiently robust as they had not ensured the delivery of consistent standards of care across the service. The provider had failed to ensure the necessary improvements had been made to the care provided since the last inspection. Most of the areas of concern we found during this inspection had already been highlighted to the provider following inspections of some of their other services. Learning had not been effectively shared to ensure that people living at The Granary received consistently safe, effective and well-led care.

Medicines were managed safely and registered nurses carried out this role with confidence. Infection control measures were adopted throughout the inspection. We received positive comments from people, their relatives and staff about the new manager. The manager was approachable and had taken time to get to know people and their needs and preferences.

The environment was spacious throughout and adapted to meet the needs of people who use wheelchairs. The home was decorated with pictures and photographs of people living at the home. Environmental risks such as hoist equipment, wheelchairs and legionella checks were managed effectively through prompt and regular servicing.

Staff employed by the home underwent a safe recruitment process. Staff had attended safeguarding adults training and knew how to protect people from abuse.

There was enough food available and offered to people throughout our inspection at mealtimes. The menu offered flexibility to meet the needs of people and their specific dietary requirements. People had access to external health care professionals including GP's who visited the home weekly.

Some people were at risk of constipation. Staff and care records demonstrated the associated risks were being managed safely. Some people had enteral feeding tubes fitted (PEG) this was also being managed safely by the staff team.

We found four breaches of Regulation at this inspection and will publish information about our actions in response to these at a later date.

We imposed conditions on the provider’s registration. The conditions are therefore imposed at each service operated by the provider. CQC imposed the conditions due to repeated and significant concerns about the quality and safety of care at a number of services operated by the provider. The conditions mean that the provider must send to the CQC, monthly information about incidents and accidents, unplanned hospital admissions and staffing. We will use this information to help us review and monitor the provider’s services and actions to improve, and to inform our inspections.

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 not enough improvement is 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.

The Granary is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. The home is registered to provide accommodation and care for up to 41 people with an acquired brain injury or neurological condition, learning and physical disabilities. At the time of our visit 11 people were living at the home, including one person who was staying for a short break.

The Granary provides accommodation across four ground floor units: Walnut, Pine, Yew and Alder. Each unit has a separate living room, dining room and kitchenette. At the time of this inspection, people were accommodated in Walnut and Alder, the other two units, which could accommodate 10 people each, were unoccupied. Rooms were of single occupancy and had en-suite facilities.

At the time of our inspection the service did not have a registered manager in post. The last registered manager left in July 2018. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated regulations. The acting manager assisted us with the inspection. The provider had put measures in place to ensure the service had adequate management support whilst they were recruiting a new manager.

Services operated by the provider had been subject to a period of increased monitoring and support by commissioners. As a result of concerns raised, the provider is currently subject to a police investigation. The investigation is on-going and no conclusions have been made. We used the information of concern raised by partner agencies to plan what areas we would inspect and to judge the safety and quality of the service at the time of the inspection. Between May 2017 and July 2018, we have inspected a number of Sussex Health Care locations in relation to concerns about variation in quality and safety across their services and will report on what we find.

This inspection was brought forward due to information shared with CQC about the potential concerns around the management of people's care needs. This inspection examined those risks.

At the last inspection on 7 and 11 December 2017 the service was rated requires improvement. The report was published in March 2018. At that inspection we identified five regulatory breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was due to the provider failing to ensure that staff received the training they needed to meet the needs of people. Some staff did not have regular supervisions as defined by the provider's policy. The provider had failed to ensure that care and treatment was provided to people with the consent of the relevant person. People were not treated with dignity and respect at all times. The provider had failed to ensure that people using the service had care or treatment that was personalised specifically for them. The provider did not have effective systems in place to assess, monitor and improve the quality and safety of the services provided in the carrying on of the regulated activity.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve each of the key question's to at least good.

At this inspection, we found although improvements had been made the registered provider remained in breach of one of the five previous breaches of Regulation. People were supported to access a wide range of activities, which included involvement and use of the local and wider community. However, people’s interests were not fully reflected in their weekly activity timetables. People were supported to express their views and be actively involved in making decisions about their care as far as possible, this was not always fully documented and reflected in their care plans. The documentation to support the monitoring of people's health needs was not always fully completed. You can see what action we told the provider to take at the back of the full version of this report.

The Granary was designed, built and registered before the guidance was published regarding Registering the Right Support and other best practice guidance. Which states, people with learning disabilities and autism using a service should be able to live as ordinary a life as any citizen. We found the provider was in the process of making improvements to demonstrate they were working in line with values such as choice, promotion of independence and inclusion when considering, planning and supporting people’s needs. The model and scale of care provided was not in keeping with the cultural and professional changes to how services for people with a learning disability and/or Autism should be operated to meet their needs. Had the provider applied to register The Granary today, the application would be unlikely to be granted. The model and scale of care provided was not in keeping with the cultural and professional changes to how services for people with a learning disability and/or Autism should be operated to meet their needs. The provider acknowledged further time was needed to demonstrate the full impact of the recent changes.

There were systems, processes and practices to safeguard people from situations in which they may experience abuse. Risks to people’s safety had been assessed, monitored and managed so they were supported to stay safe while their freedom was respected.

Arrangements had been made to ensure that sufficient numbers of suitable staff were deployed in the service to support people to stay safe and to meet their needs. Background checks had been completed before care staff had been appointed which showed that staff were of good character.

Medicines were managed safely and staff had a good knowledge of the medicine systems and procedures.

People were protected by the prevention and control of infection and lessons had been learnt when things had gone wrong.

Training was provided to staff to meet the needs of people. Staff received regular supervision and appraisal and told us they felt supported in their roles.

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. Suitable arrangements had been made to obtain consent to care and treatment in line with legislation and guidance.

People were supported with their nutrition and hydration needs. Clear guidance was available for staff to follow when people had specific dietary needs.

People received coordinated and person-centred care when they used or moved between different services. People had been supported to live healthier lives by having suitable access to healthcare services so that they received on-going healthcare support. Furthermore, people had benefited from the accommodation being adapted, designed and decorated in a way that met their needs and expectations.

People were treated with dignity and respect. Dignity was embedded in the services' values and culture. Confidential information was kept private.

There was a complaints policy and procedure made available to people who received a service and their relatives. All complaints were acknowledged and responded to quickly and efficiently. At the time of our inspection no one was receiving end-of- life care.

There was a positive culture in the service that was open, inclusive and focused upon achieving good outcomes for people. People benefited from there being a management framework which ensured that staff understood their responsibilities so that risks and regulatory requirements were met.

Quality audits were completed by the management team. These were up-to-date and completed on a regular basis. People and staff, we spoke with told us they felt the service was well-led; they felt listened to and that they could approach the management team with any concerns. Staff told us they enjoyed working at the service and enjoyed their jobs.

The views of people who lived in the service had been gathered and acted on to shape any improvements that were made. Good team work was promoted and staff were supported to speak out if they had any concerns in their work. In addition, the management team worked in partnership with other agencies to support the development of joined-up care.

We imposed conditions on the provider’s registration. The conditions are therefore imposed at each service operated by the provider. CQC imposed the conditions due to repeated and significant concerns about the quality and safety of care at a number of services operated by the provider. The conditions mean that the provider must send to the CQC, monthly information about incidents and accidents, unplanned hospital admissions and staffing. We will use this information to help us review and monitor the provider’s services and actions to improve, and to inform our inspections.

Since the registration of The Granary, services operated by the provider had been subject to a period of increased monitoring and support by commissioners. The Granary had been the subject of three safeguarding concerns about a person not receiving care in line with their health needs, a risk of injury posed by a person’s equipment and an allegation of physical abuse. As a result of concerns raised, the provider is currently subject to a police investigation. Our inspection did not examine specific incidents and safeguarding allegations which have formed part of these investigations. However, we used the information of concern raised by partner agencies to plan what areas we would inspect and to judge the safety and quality of the service at the time of the inspection. Between May and December 2017, we have inspected a number of Sussex Health Care locations in relation to concerns about variation in quality and safety across their services and will report on what we find.

The Granary is a care home that provides nursing and residential care. People in care homes receive accommodation and nursing or 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.

The Granary is registered to provide nursing and accommodation for up to 41 people with an acquired brain injury or neurological condition. At the time of the inspection, 9 people were living at the home, including one person who was staying for a short break. The Granary provides accommodation across four ground floor units: Walnut, Pine, Yew and Alder. Each unit has a separate living room, dining room and kitchenette. At the time of this inspection, people were accommodated in Walnut, the other three units, which could accommodate 10 people each, were unoccupied. Rooms were of single occupancy and had en-suite facilities.

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 2008 and associated Regulations about how the service is run.

Staff did not complete specific training to enable them to understand acquired brain injury or neurological conditions that affected people living at The Granary. Staff did not receive supervisions in line with the provider’s policy, which stated these should be completed three times a year.

People’s consent to care and treatment was not always gained in line with the requirements of the Mental Capacity Act 2005. Where people had been assessed as lacking capacity to make specific decisions, processes were not followed to ensure decisions taken were in people’s best interests.

Systems were not effective in measuring and monitoring the quality of the service provided. Where actions were identified, these had not always been completed. There were ineffective systems in place to drive continuous improvement. Monitoring records were not always completed consistently.

People were not always treated with dignity and respect, for example, how they were supported at mealtimes and how staff referred to people's personal care needs in a communal setting.

Care records did not always reflect that people received personalised care that met their needs. Some care plans relating to people’s specific areas of need lacked detailed information and guidance for staff on how to support people in a responsive way, for example, in expressing sexuality. Activities were organised but did not take account of people’s identified interests and preferences.

An area identified as needing improvement was the organisation and management of the lunchtime meal. People received their lunches at different times. Food that one person had chosen was not readily available. Fresh fruit or snacks were not freely available to people during the first day of inspection, but this was rectified by the time of our second visit. Menus were not in an accessible format to aid people’s understanding of meals on offer.

People said they felt safe living at The Granary and staff understood what action to take if they had any concerns about people’s safety. Staff had completed training in safeguarding adults at risk. Risks to people were managed safely overall, but there were some gaps in records which was an area that needed improvement. By the second day of inspection, action had been taken to complete gaps we had identified in relation to fluid recording and repositioning charts. Staff knew people well and were knowledgeable about potential risks. Staffing levels were within safe limits. Recruitment systems for new staff were fit for purpose and ensured that appropriate checks were made before staff commenced employment. Medicines were managed safely. Appropriate infection control procedures were implemented by staff. Accidents and incidents were recorded, together with outcomes for people.

People and/or their relatives were involved in making decisions relating to their care and with care planning. A variety of facilities was available to people living at The Granary including access to a salt cave, hydrotherapy and a gym and day centre at one of the provider’s other locations. People commented positively about the staff and felt their individual needs were met. Staff completed mandatory training in a range of areas and an induction programme. People had access to a range of healthcare professionals and services including physiotherapy and general practitioners. Premises were accessible for wheelchair users, but were not specifically designed to meet the needs of people with an acquired brain injury or neurological condition.

People were looked after by kind and caring staff who knew them well. People’s communication needs had been identified and were catered for. Where needed people had assistive technology to help them communicate effectively. Some people had access to advocates to support them in making decisions.

Some care plans were detailed and fit for purpose. People’s spiritual and cultural needs were catered for. As much as they were able, and if they chose, people were involved in reviewing their care plans. People knew how to make a complaint. People’s wishes and preferences for their end of life care had been recorded. Staff had completed training in areas relating to end of life care.

The registered manager described the culture of the home and the importance of recruiting the right staff. He talked about the new Key Lines of Enquiry (KLOE) which the Commission introduced from 1 November 2017. The registered manager planned to discuss these with staff at a staff meeting. Staff felt supported and valued by the registered manager. People and their relatives were asked for their feedback about the home and residents’ meetings took place. The registered manager worked in partnership with other agencies.

At this inspection we found the service was in breach of five regulations 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.