Archived: The Grange

The Grange is a residential care home providing personal care and accommodation for up to 29 older people. There are 26 single rooms which are used as single rooms unless anyone has a specific need to share. The service provides support to older people who are able to independently mobilise around the service. At the time of our inspection there were 25 older people using the service.

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

Everyone told us they would recommend the service due to the care and attention of the staff. One person told us, “The owners, you can just feel that they care. Their priority is the care of the residents and not money.” Another person told us, “The staff are all great. Nothing’s too much trouble for them, some are actually more like friends to me now, rather than my carers.”

The aims of the service was for people who were independently mobile, to maintain their independence, make decisions made about their care and continue with histories and hobbies. Staff effectively supported people to achieve these aims.

People and their relatives said the service was well-managed and the managers and owners were open and approachable. A positive culture had been nurtured at the service where people felt confident to speak up and their views were listened to and acted on.

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.

There were enough staff available to meet people’s needs. People said they never had to wait a long time to be supported and staff had time to sit and chat to them, which they very much enjoyed. Staff were provided with suitable training to ensure their skills and knowledge were up to date. Staff felt well supported by the management team, which helped them to provide person-centred care.

People had access to health care support and the service worked in collaboration with health care professionals to ensure their health needs were met. People received their medicines as prescribed.

Quality checks ensured people received safe, effective and responsive care. These checks included feedback from people and their relatives to help the service improve.

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 3 December 2019).

Why we inspected

We undertook this inspection as part of a random selection of services which have had a recent Direct Monitoring Approach (DMA) assessment where no further action was needed to seek assurance about this decision and to identify learning about the DMA process.

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.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice.

People were well supported by staff to have telephone and internet contact with their family and friends. The service facilitated in person visits in a manner which minimised the risk of infection spread, including screened and garden visits.

Plans were in place to isolate people with COVID-19 to minimise transmission and an isolation room was used for people admitted to the home from hospital or the community. The service had good supplies of personal protective equipment that were readily available at stations throughout the service.

Visitors were asked health screening questions and to wash their hands on arrival with soap and water. Temperature checks and lateral flow tests were carried out and once a negative result was received staff facilitated the visit. Visits were staggered and visiting spaces cleaned between use.

Staff had received training on how to keep people safe during the COVID-19 pandemic and staff and residents were regularly tested for COVID-19. The building was clean and free from clutter and there were enhanced cleaning practices.

Staff ensured people’s welfare had been maintained and they had sufficient stimulation, such as quizzes and games. People were also able to go for walks, escorted by staff.

The Grange is a residential care home in Ashford, Kent, providing personal care to older people, some of whom may have mild forms of dementia or other illnesses. The service can support up to 29 people and at the time of the inspection, 26 people were living in the home.

The home is a two floor building. Each floor or unit has separate adapted facilities.

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

Medicines were managed safely. There were procedures to protect people from abuse and staff understood how to report abuse. Risks associated with people's needs were assessed thoroughly. Staff followed infection control procedures to maintain the hygiene and cleanliness of the home. Accidents and incidents were reviewed to learn lessons to help prevent them re-occurring. Staff were recruited safely and their backgrounds were checked before they started working in the home. The home had suitable numbers of staff available at all times to provide support. Premises and equipment safety was maintained to ensure the environment was safe for people. We have made a recommendation for the provider to look into obtaining an external fire risk assessment of the home because the provider carried this out themselves and was not a fire safety professional.

Staff were provided with suitable training to ensure their skills and knowledge were up to date. Staff felt supported by the registered manager. They received regular supervision to monitor their performance.

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 maintained their health and nutrition with balanced meals. The service worked in collaboration with health care professionals, such as GPs and physiotherapists to ensure their health needs were met.

There was a culture and ethos of providing excellent care to people. Staff and managers developed strong relationships with people and relatives. Staff often exceeded expectations to ensure people received care that was personalised. Staff were exceptionally kind, respectful and caring. They understood the importance of promoting equality and diversity. People were supported to remain independent and lead a private life. They were involved in decisions made about their care and staff took an active interest in people's histories and hobbies.

Staff knew about people’s communication needs and what techniques to use for people who found it difficult to communicate. Activities took place in the home and people were encouraged to participate in them if they wished. Staff interacted and engaged with people throughout the day. People were supported to avoid social isolation and pursue their interests.

People and their relatives were supported to make complaints about the home. There were quality assurance systems to monitor the safety of the home through audits and obtaining feedback from people and relatives.

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 6 June 2017).

Why we inspected

This was a planned inspection based on the previous rating.

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.

There was a registered manager in post. A registered manager is a person who is 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 previous inspection in May 2016, we found that the provider was not meeting all the regulations inspected at that time because the quality monitoring system in place were not effective. Medicines administration and recording needed improvement as did the recording of fire drills, and tests of fire equipment. The service at that time had also not ensured that The Care Quality Commission was informed of notifiable events.

Staff spoke kindly to people and treated them with respect. People were able to make decisions and choices for themselves about what they did, and where they ate their meals and with whom, people were encouraged where possible to maintain their independence seeking support when needed.

At this inspection we looked at the improvements made in these areas and was satisfied these had been addressed appropriately. The provider, who was a visible presence in the service, had taken steps to ensure greater involvement in the day to day operation of the service. This helped to relieve the registered manager of some responsibilities in regard to the completion of paperwork meaning they could increase their focus on care delivery. Investment in an electronic records system provided the facility for the registered manager and the registered provider to have greater oversight and scrutiny of day to day care delivery, even remotely when not on site. This enabled the registered manager and provider to check at any time of day or night, the support provided to people, the administration of their medicines, food and fluid intake, personal care routines supported and activities participated in. This provided them with greater assurance that all aspects of the service were meeting requirements consistently and systems in place were being carried out as per their own policies and procedures.

More robust recruitment practice meant that staff suitability for the role was assessed through a full range of checks in line with legislation requirements. Medicines were managed well and observed staff practice showed improvements in the way administration was undertaken and recorded. Staff understood how to keep people safe from abuse and harm. In the event of a fire or event requiring evacuation staff had had practiced for this and the registered manager ensured all staff attended a minimum of two practice drills per year. Staff understood where to take people to keep them safe. The premises were well maintained. All areas viewed were visibly clean and cleaning staff told us about their cleaning schedules each day. All necessary equipment servicing, checks and tests were carried out. The Provider also carried out an annual health and safety check to ensure that the environment was safe and that equipment was in good working order.

The majority of individual and environmental risks to people’s safety were assessed and managed appropriately. There was a low level of incidents and accidents and staff took appropriate action when these occurred, the registered provider and registered manager understood what events they needed to notify the Care Quality Commission about.

The registered manager undertook pre-admission assessments of people referred to the service to assess their dependency and whether their needs could be met within the service. They had a clear understanding of what needs could and could not be catered for, this ensured that there was enough staff on duty during the day and night to meet people’s individual needs, and when people’s needs changed they ensured there was dialogue with all parties to discuss whether more appropriate placements should be sought. People’s care, treatment and support needs were clearly identified in their plans of care and included people’s choices and preferences. Staff knew people well and understood their likes and dislikes, people were involved and consulted about the content of their care plans.

CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards. The manager and staff showed that they understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). People had capacity and their consent and involvement was always sought in regards to their daily support needs, they lived their lives without any imposed restrictions that deprived them of their liberty unnecessarily.

People were offered an appropriate range of activities and were consulted about changes to this at residents meetings. Relatives and friends were made welcome and people were supported to keep in contact with people who were important to them. People understood how to complain and felt confident if they needed to raise issues these would be handled appropriately by the registered manager or provider.

Health professionals told us that people’s health needs were understood and well supported by staff. People were given support to attend health appointments with a wide range of health professionals; any advice given in regards to their health needs was implemented. People ate well and their likes and dislikes were catered for. Weights were monitored and concerns about weight loss and nutritional intake were referred appropriately to medical professionals.

New care staff received induction to their role that involved completion of the Care Certificate if they had no previous care experience. New staff were given time to familiarise themselves with the service routines and peoples individual needs. They shadowed experienced staff until they were confident of working on shift unsupervised and an understanding of how to deliver personal care support to people in accordance with their needs and preferences. There was a programme of mandatory training for all staff that provided them with basic knowledge and awareness of food hygiene, infection control, first aid, and fire awareness in addition to keeping people safe from abuse, awareness of dementia, nutrition, and mental capacity. Not all staff had yet completed the full range of their training and this was an area for improvement.

We have made one recommendation:

We recommend that the registered manager seek advice from a relevant health professional to identify what additional information should be contained in some of the health risk assessments completed for people for example with diabetes.

This service was last inspected on 29 August 2014 under previous methodology and at that time the provider was found to be compliant and no breaches of regulations were identified.

There was a registered manager in post. A registered manager is a person who is 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 told us they were happy living at the service, their relatives also spoke positively about the quality and delivery of care provided to their family members. Professionals we spoke with during and after the inspection spoke positively about the good working relationships the staff fostered with professionals, and the quality of care they provided to people.

Systems that the service had in place to protect the safety and wellbeing of the service users not always being followed; this could place people at risk. The lack of a comprehensive quality monitoring system meant the provider and registered manager could not be assured that all aspects of the service were meeting people’s needs..

Recruitment procedures and checks of new staff were made but this needed improvement to ensure these were carried out thoroughly and in line with regulatory requirements. The management of medicines ordering, receipt, disposal and administration was managed well and people received their medicines in a personalised manner that took account of their preferences; improvement however, was needed to the way in which medicines administration and changes to medicine records were made. Fire alarm and emergency lighting tests were not conducted in accordance with the homes fire risk assessment and although staff said they attended fire drills, there was no evidence for this to ensure they understood how to respond in the event of a fire.

The service had not consistently notified the Care Quality Commission about people who had experienced a serious injury that required hospital treatment as required by regulation. The risk assessment framework used needed expanding to ensure all potential risks people may be subject to were assessed and measures implemented to reduce risk of harm occurring.

Staff treated people respectfully, showed kindness and patience and we saw many examples of positive interactions from staff towards people. Staff placed people at the centre of the support they provided and delivered this in a personalised way to meet individual needs.

People and their relatives told us they felt informed by the staff and that communication was good. They were asked for their views and people felt able to voice their comments openly in user meetings. People ate a varied diet, specialist diets were catered for and people were able to request alternatives to the menu if they wanted to.

The premises provided a pleasant comfortable clean and well maintained environment and people appreciated and valued the lovely grounds and the period appearance of the premises. Staff understood how to keep people safe from harm. There were enough staff to meet people’s needs. New staff received appropriate induction and all staff completed a regular programme of training. Staff understood and worked to the principles of the Mental Capacity Act 2005.

People enjoyed the activities provided for them and were consulted through meetings and questionnaires about what else they might want to do. People and their relatives were consulted about their care needs and staff kept these under review. People and relatives understood the complaints procedure and felt confident any issues if they had any would be addressed immediately. Staff felt supported and listened to, the registered manager and the provider had a visible presence in the service throughout the week and there was a good sense of team work amongst them.

We have made one recommendation:

We recommend that the provider consult the Fire Service regarding personal emergency evacuation plans for people that state they can be left behind fire doors to await evacuation by the fire service to ensure these meet current fire legislation Regulatory Reform (Fire Safety) Order 2005.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.

We looked at the answers to five questions: Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

Is the service safe?

We saw that the home was visibly clean in all areas and was well maintained. The premises included spacious gardens which were attractively presented. There were reliable procedures in place to manage on-going maintenance.

We inspected medicines management and found that suitable procedures were in place to ensure that people received the right medicines at the right time, with the support of appropriately trained staff.

We found that the management staff had procedures in place to ensure that people consented to the care and support provided for them. None of the people in the home lacked the mental capacity to make day to day decisions, and most were able to make complex decisions. One of the providers and the manager showed us that they understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS), to apply for DoLS if this was indicated. This would apply to people who might be assessed as needing their liberty restricted for their own safety. We saw that people's next of kin or authorised representative were included in complex decision-making and consent procedures where people living in the home had delegated this to them.

Is the service effective?

We saw from looking at care planning that people were assessed prior to their admission to ensure that the home would be able to meet their assessed needs. This included people having sufficient mobility to move around without the need for hoisting facilities and wheelchairs within the home, as the premises were not suitable for using this sort of equipment. However, the premises did include two lifts to all floors, and assisted bathing facilities.

We found that care plans contained clear information which enabled staff to provide effective care. The care plans were reviewed monthly, and were updated prior to this if people's needs changed.

The home provided people with a variety of food and drinks to meet their different nutritional needs. People said that the food was very good, and they had 'more than enough'.

Staff had been trained in required subjects such as health and safety, moving and handling, infection control and fire safety. We saw that this training was kept up to date. Other relevant training courses were provided so that staff could develop their knowledge in line with the needs of people living in the service, such as training in diabetes.

Is the service caring?

The home was a family run business and this was reflected in the care given by the staff, in that people living in the home said 'It feels like a big family here'. All of the people that we spoke to were very positive about the home's relaxed atmosphere and the kindness of the staff. People's comments included, 'Everyone is so kind, it is lovely here'; and 'It is excellent here. It is a home from home, and the staff are wonderful.' We saw that recent questionnaires also included very positive responses, with remarks such as 'The girls (i.e. care staff) are very good; the Grange is very good indeed.'

We saw that staff took time to chat with people, and assisted them to sit where they wanted to. They ensured that people had the things they needed next to them, such as a drink, their handbag and a call bell pendant if they required this. The pendants enabled people to call for staff from anywhere within the building.

The home enabled people to carry out their choice of daily activities, with newspapers, books and televisions available. A range of shared activities was provided during the week for those who wished to join in with these.

Is the service responsive?

The home had an arrangement with a local GP surgery for weekly visits to the home. Most people chose to be registered with this practice. This enabled people to see their doctor as needed.

The staff had systems in place to monitor people's general health, so that staff were aware more quickly if people might be unwell or need medical advice. People were referred to other health care professionals as needed for further advice, such as dieticians, opticians, community nurses and dentists.

People said that if they had any concerns they would ask to speak to the manager. They were confident that she would investigate any concerns thoroughly and would take action to deal with anything needed. People spoke highly of other staff too, and two people said 'I would ask the care staff for most things, and then the manager if I needed to.' The manager and one of the providers oversaw the day to day running of the home, and spoke to most people each weekday to see if they were happy with how the home was being run.

Is the service well-led?

We saw that people in the home knew the manager and providers well, and had confidence in them to deal with any issues.

Staff said that they had daily handovers, and changes were discussed during these times. They used a communication diary to record any day to day changes to ensure things were not missed. Staff meetings were held to enable staff to discuss relevant issues and raise new ideas. The manager carried out individual supervision with staff every two to three months; and yearly appraisals were completed. This provided staff with the opportunities to discuss individual training needs, and to develop within their different roles.

People living in the home saw the manager or one of the providers nearly every day, so they could easily raise any issues or concerns. We saw that residents' meetings were held so that people could discuss things together. People's views were also obtained through twice yearly questionnaires. The results of these were analysed, and action was carried out to respond to any identified changes.

The home had monitoring procedures in place. This included regular checks for maintenance and safety, such as checking water temperatures, checking the nurse call bell system, and checking fire alarms and fire equipment.

People said they were involved in decisions about their care and treatment. One person told us that staff "Value people's views and decisions".

We found that people were involved in their care planning and that their care plans had regular monthly reviews. This meant that people's care plans were updated as their needs had changed and therefore, their care was tailored to their current needs.

People told us they felt safe at the service and their personal belongings were looked after. One person told us they had a "Lockable draw to put things in...but there were no problems...everything was very safe". People were confident in talking to their key worker, staff or the manager if they had any concerns and felt the service would deal with any concerns promptly.

Staff told us there were enough staff to provide safe and effective care. A member of staff said "There is a good skill mix" and that they had no concerns regarding the skill base. They said "Everyone works as a team".

People and their relatives were invited to express their views and opinions by talking to the manager and staff, through "a suggestion box and resident meetings" and on their visits to the service.

People told us they were involved in the planning of their care and were able to speak to their key worker or manager if they wanted changes in the support being provided or had any concerns about their care. People said they felt safe in the service and that their personal property was respected.

The service was clean and tidy. People felt they lived "Very comfortably" in the service and "Enjoyed a good lifestyle". They told us they talked to the staff about any problems they had and actions had been taken to address any issues they had.