The Grange Care Home

The Grange is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service is a large detached property. Accommodation is arranged over two floors and a lift is available to assist people to get to the upper floor. The Grange Care Home provides care for up to 28 older people living with dementia, frailty and mobility care needs. There were 11 people living at the service at the time of our inspection.

There was no registered manager at the time of our inspection. However, the manager of a sister service, owned by the same provider, had applied to become the registered manager of The Grange. Their application had been received by CQC and was being processed. Their registration to manage The Grange was intended to be temporary, this was because a new manager for The Grange had been appointed and was receiving mentoring for the role. Once established, the new manager would apply for the registered manager post at The Grange and the manager of the sister service would return to their original service. 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 temporary manager is referred to as the temporary manager and the new manager is referred to as the acting manager in this report. Jointly, they are referred to as the managers.

Our last inspection of this service took place in July 2018. This was a focussed inspection which looked at the key areas of Safe, Effective and Well Led. Each of these areas were rated as Requires Improvement, together with the overall rating of the service. This was because requirements about the administration and storage of some medicines were not always complied with. Recruitment processes were not as thorough as needed because some gaps in employment history were unexplained and some references from previous employers were missing. The service was not suitably well led because a number of checks and audits failed to address shortfalls in the safety and quality of the service provided. We also found the provider had failed to comply with a condition of their registration because they had not made suitable arrangements to have a registered manager in post.

This inspection was completed on 6 November 2018. It was a full inspection which looked at all five key areas of the service. At this inspection we found improvements had been made and the breaches of regulation identified at the last inspection had been met.

The management of people’s medicines was safe. Risks had been identified and action had been taken to manage them. Records about people and the care they received were accurate, complete, held securely and easily accessible to staff when they needed them.

There were enough staff to provide the care and support people needed when they wanted it. New staff were recruited safely. Disclosure and Barring Service (DBS) criminal records checks had been completed to make sure staff were suitable for their role. Staff were supported meet people’s needs and had completed the training they needed to fulfil their role.

Staff were kind and caring and treated people with dignity and respect. They took time to get to know each person well and provide the care people wanted in the way they preferred. People received the care and support they wanted at the end of their life.

Assessments of people’s needs and any risks were completed and care had been planned with them, to meet their needs and preferences and keep them safe. Accidents and incidents were analysed to look for patterns and trends. The temporary manager worked in partnership with the local authority safeguarding and commissioning teams as well as a clinical nurse specialist for older people. The service had acted on their advice to develop the service and improve people’s care.

Staff knew the signs of abuse and were confident to raise any concerns they had with the managers or provider. People were not discriminated against and received care tailored to them. A process was in operation to investigate and resolve complaints to people’s satisfaction. People had enough to do during the day, including activities to keep them physically and mentally active.

Changes in people’s health were identified and people were supported to see health care professionals, including GPs when they needed. People were offered a balanced diet of food they liked, which met any specific dietary or cultural needs and preferences. Staff supported people to be as independent as they wanted at mealtimes.

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. The managers knew when assessments of people’s capacity to make decisions were needed. Information was available to people in a way they understood to help them make decisions and choices. Staff treated people with dignity and gave them privacy. The managers understood their responsibilities under Deprivation of Liberty Safeguards (DoLS) and had applied for authorisations when there was a risk that people may be deprived of their liberty to keep them safe.

Staff felt supported by the managers and were motivated. A member of the management team was always available to provide the support and guidance staff needed. Staff worked together to support people to be as independent as they wanted to be. All the staff we spoke with told us they would be happy for their relatives to live at The Grange and that they were proud to work there. The views of people, their relatives, staff and community professionals were asked for and acted on to continually improve the service.

The service was clean, staff followed infection control processes to protect people from the risk of infection. The building was well maintained, plans were in operation to maintain and improve the environment. People were able to use all areas of the building and grounds.

The managers had informed CQC of significant events that had happened at the service, so we could check that appropriate action had been taken.

Services are required to prominently display their CQC performance rating. The provider had displayed the rating in the entrance hall and on their website.

Further information is in the detailed findings below.

The Grange Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The Grange Care Home accommodates up to 28 people in one adapted building. At the time of our inspection there were 14 people using the service.

There was no registered manager at the time of our inspection. The registered manager left the service in April 2017, and a registered manager has not been at the service since this date. The service was being managed day to day by an interim manager who is referred to as the manager throughout this report. 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 Grange was last inspected in March 2018. At that inspection, it was rated as ‘Inadequate’ overall. A number of breaches of regulation were found during that inspection and the service was placed into special measures.

At this inspection people and their relatives continued to give good feedback about the service. We found some areas where there had been improvements, and some areas where sufficient improvement had not been made, including to areas previously identified resulting in continued breaches of regulation.

Previous issues relating to creams management and transdermal patches (a medicine applied to the skin) remained unresolved putting people at potential risk. Gaps in staff recruitment records had been identified by the manager as needing to be resolved but at the time of our inspection this had not been done.

Improvements had been made to risk assessments. These now provided clear guidance to staff of the identified risk and how to minimise the risk, however we needed more assurance that the progress made would be sustained. Staff understood their responsibilities in relation to safeguarding, and could identify warning signs they would look out for if they had concerns about people. Staffing levels had improved since our last inspection. There had been improvements in relation to infection control; the previous odour in communal areas had been addressed. The provider had further plans to improve this area by replacing the carpets in the service. Accidents and incidents had been documented and improvements made when things went wrong.

People’s needs were re-assessed when they were re-admitted from hospital. However, work was on-going and slow in re-writing people’s care plans to ensure they were person centred and considered protected characteristics and preferences. Staff training and induction had improved, with new staff telling us the induction process gave them the tools to be able to do their role effectively. People were supported to maintain a balanced diet. The staff team worked with external healthcare professionals to provide people with on-going healthcare support. Improvements had been made to the premises to ensure there was dementia friendly signage throughout the home.

There was a strategy to drive improvement which was shared by staff and the management. People and their relatives were asked for their feedback about the service, and how to improve it. Staff understood their role in the organisation, and the management submitted the necessary notifications. The manager had developed good working relationships with healthcare professionals.

We found a number of continued breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we asked the provider to take at the back of this report.

The Grange is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The Grange Care Home accommodates up to 28 people in one adapted building.

There was no registered manager in post at the time of our inspection. The last registered manager left the service in April 2017. There has not been a registered manager at the service as required since April 2017. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Registered persons have a legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated Regulations about how the service is run. A new manager had started work in the service on 15 January 2018 and had recently submitted a registration application to CQC.

The Grange Care Home was last inspected in July 2017. At that inspection it was rated as 'Inadequate' overall. A number of breaches of Regulation were found during that inspection and the service was placed into special measures.

At this inspection, although people and relatives gave mainly positive feedback about the service, and we found partial improvement in some areas; we continued to have significant concerns about the safety and well-being of people. Emerging risks were seen in areas where there had been no previous concerns and breaches and continued breaches of Regulation were found.

Risks including those associated with medicines, the environment, hot water temperatures, the spread of infection and fire drills had not been properly assessed or minimised in order to keep people safe. There had been partial improvements to medicines management but these were not sufficient to make medicines safe overall.

There were not enough staff to safely meet people’s needs and recruitment process were not robust enough to ensure that only suitable staff were employed. Staff training was not wholly effective in some areas. There was minimal evidence that lessons had been learned and improvements made when things went wrong.

People’s healthcare had not been effectively monitored and concerns escalated in a timely way. Care plans did not always reflect the current position which left people exposed to risk of receiving inappropriate care or treatment.

The principles of the Mental Capacity Act 2005 and the associated Deprivation of Liberty Safeguards had not been properly understood or applied in the service.

There was little adaptation to the premises to make them suitable for older people and those living with dementia. Not all people were consistently treated with dignity. People’s involvement in care decisions and planning was not clearly evidenced.

Care plans and risk assessments were not sufficiently person-centred and in some cases did not provide step by step guidance to staff to enable them to support people in a consistent and safe way. End of life care plans required further input to make them truly person-centred. Responses to complaints were not always put into action effectively.

The service was not well-led. Issues raised at our last inspection remained unaddressed in some cases and new problems emerged in other areas. Auditing had been ineffective in identifying shortfalls. There was little evidence of people’s involvement in their care or decisions about it.

Most people enjoyed a range of activities but some people being cared for in bed or living with dementia did not always receive the same level of stimulation.

Staff had received safeguarding training. They were aware of how to recognise and report safeguarding concerns. The new manager had begun to carry out staff supervisions and implement competency checks.

People had routine appointments with GPs, health and social care specialists, opticians, dentists, chiropodists and podiatrists. People enjoyed their meals and were supported to eat if necessary.

Staff were kind and caring and went out of their way to make visitors feel welcome. People were encouraged to remain as independent as possible. We received mostly positive feedback from the people, relatives and visitors who were able to speak with us.

People, relatives and staff felt the new manager was approachable and responsive. Feedback had been sought from people and their families through questionnaires and meetings.

The new manager was engaged in joint working with the registered manager of the provider’s sister service and received regular input from the Clinical Commissioning Group, local authority and a range of visiting health professionals.

The service notified the Commission of incidents and events that they were legally required to and had displayed their CQC rating.

We found a number of breaches and continued breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The Grange Care Home is registered to provide personal care and accommodation for up to 28 older people. The service was fully occupied during our inspection. Some of the people at the service were living with dementia and other conditions requiring support such as diabetes or impaired mobility, however, other people were more independent.

The Grange is a large detached house situated in a residential area just outside Folkestone. The service has a large communal lounge with comfortable seating and a separate dining area as well as quieter areas for people to sit. Accommodation is set over two floors and upstairs bedrooms can be accessed by stairs and a passenger lift. There are good sized gardens to the rear and side of the premises.

A registered manager was not in post. The registered manager left the service in April 2017 and since then the deputy manager undertook the role of acting manager, overseeing the day to day running of the service. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Registered persons have a legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated Regulations about how the service is run. It is a condition of the registration of the service that a registered manager must be in post. The service were actively recruiting for the post of registered manager and, following the inspection, an application to register a manager has been received.

The Grange Care Home was last inspected in July 2016. At that inspection it was rated as 'Requires improvement'. A number of breaches of Regulation were found during that inspection and three warning notices were issued to the registered manager and provider telling them urgent improvement must be made. This was in relation to how medicines were managed, problems with recruitment processes and how the service was led by the registered manager and service provider. Other Regulation breaches were found around the cleanliness of the service and inadequate checks to monitor standards of hygiene and cleanliness. These were addressed with a requirement action and the provider wrote to us setting out how they would improve.

At this inspection, although people and relatives gave mainly positive feedback about the service, standards had deteriorated. Some concerns brought to the attention of the provider in previous warning notices remained of concern and new breaches of Regulations were found.

Medicines were not administered or stored safely; poor communication meant some medicines were not requested when people needed them.

Some risk assessments were not up to date to reflect people’s current needs and when risk assessments were in place, staff did not always follow the procedures of safe practice that they set out.

Checks intended to safeguard against the risk of scalding water had lapsed and where they had previously identified water temperatures outside of a safe range, no action was taken to address this. Other checks intended to safeguard against the presence of water borne bacteria were incomplete.

There were not enough staff to safely meet people’s needs and there was no method to review or monitor staffing requirements against people’s needs. Mandatory fire drills had not taken place.

Some mental capacity assessments were contradictory and Deprivation of Liberty Safeguarding authorisations had not been applied for where it was reasonable to believe that people were unable to consent to restrictions in place.

Records of staff induction training were muddled and certificates of completed training were not readily accessible. Competency assessments had not been completed for new staff before they worked unsupervised and some people complained of poor care delivery.

People’s privacy and dignity was not assured; staff did not recognise situations where intervention was needed to ensure people’s experiences of living at The Grange were not adversely affected.

The complaints handling process was ineffective; verbal complaints or concerns were not recorded and written complaints were not tracked or dealt with in a way the met the service’s policy.

Auditing carried out for the purpose of identifying shortfalls in the quality and safety of the service provided had not been effective; they had failed to identify the concerns evident at this inspection or address some concerns highlighted at the previous inspection.

Staff had received safeguarding training. They were aware of how to recognise and report safeguarding concerns.

Proper pre-employment checks had taken place to ensure that staff were suitable for their roles and a programme of regular and refresher training was in place.

Healthcare needs had been assessed and addressed. People had regular appointments with GPs, health and social care specialists, opticians, dentists, chiropodists and podiatrists to help them maintain their health and well-being.

Most people enjoyed their meals, they were supported to eat when needed and risks of choking, malnutrition and dehydration had been adequately addressed.

People had been involved in their care planning and care plans recorded the ways in which they liked their support to be given. Bedrooms were personalised and people’s preferences were respected. Independence was encouraged so that people were able to help themselves as much as possible.

People commented positively about the openness of the acting manager and were complimentary of the staff.

The service notified the Commission of incidents and events that they were legally required to.

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 Grange is registered to provide personal care and accommodation for up to 28 people. There were 25 people using the service during our inspection; who were living with a range of health and support needs. These included; diabetes, catheter care and people who needed support to be mobile.

The Grange is a large detached house situated in a residential area just outside Folkestone. The service had a large communal lounge available with comfortable seating and a TV for people and separate, quieter areas. There was a secure enclosed garden to the rear of the premises.

A registered manager was in post. A registered manager is a person who has registered with the care Quality Commission to manage the service. 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 Grange Care Home was last inspected in November 2014. At that inspection it was rated as ‘Requires improvement’. A number of breaches of Regulation were found during that inspection and the provider sent us an action plan to tell us what actions had taken place to make improvements. The action plan stated that the breaches had been addressed by June 2015.

At this inspection we found that improvements had been made but some areas required further input to make them better.

Medicines had not always been managed safely but other risks had been properly assessed and actions taken to minimise them. Some areas of the service were not appropriately hygienic; while others were clean and fresh.

Recruitment practices were not sufficiently robust but there were enough trained and skilled staff on duty to meet people’s needs. Staff received regular supervision and appraisal to develop them.

Safeguarding processes were understood by staff and updated policies supported them. Accidents and incidents were properly recorded, monitored and actions taken to prevent recurrences.

People had enough to eat and drink and enjoyed their meals. Records of food intake were not detailed enough until the registered manager introduced new charts during our inspection. People had input from dieticians and other professionals when necessary and healthcare needs were kept under review.

Some people living with dementia would be prevented from leaving the service if they tried to go out alone, as this would not be safe for them. However, there were no Mental Capacity Act (MCA) assessments or Deprivation of Liberty Safeguards (DoLS) applications for these people. We made a recommendation about this.

Staff were warm, caring and respectful. People and relatives told us they would not hesitate to recommend the service to others. A range of activities were on offer and staff spent one-to-one time with those who chose not to be involved in them.

People and relatives knew how to complain but said they had had no cause to. There was a complaints policy and process in place and people’s feedback was sought through meetings and surveys.

Audits and spot-checks had not always been effective in identifying shortfalls in the quality of the service. Staff felt supported by the registered manager and said they worked well as a team. There was an open culture where staff could speak out and they understood their responsibilities to keep people safe.

We recommend that the provider carries out a full review of mental capacity within the service and considers submitting (DoLS) applications if this is then deemed appropriate.

We found a number of breaches in 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 this report.

People we spoke with who lived at the home told us that they were happy with the care and support they received. One person said 'I would recommend this place to anybody'. Another person said 'I have been ever so happy here'. A visitor commented 'I am happy with the care, definitely'.

People told us that they were supported to make their own day-to-day decisions and were involved in how their care and support was provided.

We found that care plans contained details about people's daily routines, their care needs and the support they required from staff. Risk assessments were in place to identify and minimise risks as far as possible for people who lived in the home.

We found that people enjoyed the food and were able to make choices about the meals they received. Staff were aware of people's dietary needs and helped to ensure people were protected from the risks of inadequate nutrition and dehydration. One person told us 'the food is lovely' and a visitor told us 'the food is really good'.

We found that there were enough suitably trained staff to support people's needs. One person we spoke with who lived in the home told us 'the staff are good to you; nothing's too much trouble, they're wonderful'.

The home had a complaints policy and a procedure that was followed to enable the manager to respond and address complaints in a timely way.

In this report, the name of the registered manager appears who was not in post and not managing the regulatory activities at the home at the time of our inspection. Their name appears because they were still registered with us at the time of our inspection.

People who used the service told us there were social activities on a regular basis and they could choose to join in or not as they felt fit. People told us the staff were kind and respectful and responded quickly to their needs. One person told us 'I like it here and can't imagine a nicer place to live"

We saw staff were supportive and spoke to people in a respectful manner. We observed staff refer respectfully to people on day to day choices and decisions on things such as where they preferred to sit and what they preferred to drink.

We looked at individual risk assessments that evidenced people who used the service were supported and encouraged to be independent. We looked at the providers safeguarding policies and procedures and saw the safeguarding vulnerable adults, aggression and abuse policies were all current. We were told by people who use the service that they attend residents meeting every month and were encouraged to have 'their say' about any issues they had.