The Grange Residential Hotel

• Every person we spoke with fed back that staff were caring and they were happy living in the service. Relatives told us the service felt like a home and they were made to feel welcome when they visited their loved ones.

• Bedrooms were personalised and people had their photographs on display, there was the smell of home cooked food and baking throughout the building. Some building improvements needed to be made to modernise the facilities but the provider had already planned these.

• Staff felt supported and had received enough training to enable them to support people in line with best practise guidance. Staff told us they enjoyed their jobs and had a good understanding of person centred care.

• People were offered choices in their day, the registered manager had good knowledge of the Mental Capacity Act 2005 (MCA).

• There had been several improvements introduced since our last inspection. Records were more accurate and contained more detailed risk information for specific health conditions.

• The quality of the care was regularly audited and care improved as a result. Issues were followed up with staff and relatives and people were encouraged to feed back to the registered manager.

• People’s health needs were met with referrals to health professionals where needed. Regular contact was had with the district nurse and GP, both of whom gave positive feedback about the service.

• Medicines were managed safely and administered calmly. Recording was accurate.

• Activities were daily and offered a range of different things to do but these were not always to people’s tastes. Improvements to the activities offered were underway at the time of our inspection.

More information is available in the detailed findings sections below.

Rating at last inspection: Requires Improvement (report published 23 November 2017)

About the service: The Grange Residential Hotel (hereafter referred to as The Grange or the service) is a residential care home that was providing personal and nursing care to 14 people aged 65 and over at the time of the inspection. The service is in an adapted period property in the village of Ipplepen in Devon.

Why we inspected: This was a planned inspection based on the last rating. This service is a service that has been rated requires improvement in two out of three previous inspections.

At the time of this inspection 15 people were living at the home and seven people were living in the supported living service, although none of these people were receiving support with their personal care needs. As CQC is only responsible for looking at personal care delivered at the supported living service, we did not inspect that service on this occasion.

At the time of our inspection the home had a registered manager. However, the registered manager was on maternity leave. We were supported during the inspection by the deputy manager and a registered manager from one of the registered provider’s other care homes. 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 in the Health and Social Care Act and associated Regulations about how the service is run.

In September 2016 we carried out an unannounced comprehensive inspection of this home. The home was rated as ‘good’ overall with ‘requires improvement’ in the key question ‘Is this service safe?’ In July 2017 we received concerns in relation to how risks to people were being managed, the management of accidents and incidents at the home, staffing levels and the leadership of the home. There were concerns that people's charts, for example, food and fluid charts, falls records and accidents and incident forms, were not being recorded correctly.

We initially undertook a focused inspection on 24 July 2017 to look into those concerns but changed this to a comprehensive inspection.

People's feedback about the home and the management of the home was positive. People said the deputy manager and registered manager were approachable and had confidence in their ability to manage the home. We found that governance systems to monitor the care quality and safety at the home had not always been effective. We identified a number of areas that required improvement.

Some risks associated with people’s particular health needs had not always identified or mitigated. Care plans and risk assessments were not always updated when people's needs changed. This meant that staff could not ensure they were managing people's needs and risks effectively. People’s care records did not always contain sufficient guidance for staff to minimise risks to people.

People received their medicines safely and as prescribed. Records relating to some topical medicines were not always up to date. The room where medicines were stored was hot during the days of inspection. Staff took immediate action to address this. Staff received training and their competence had been assessed.

We made a recommendation to the provider about their medicine auditing and monitoring processes.

Records we looked at showed that people did not always have assessments of capacity in place where required and the outcomes of any best interests decisions made on their behalf were not always documented. We saw that staff had not completed training in regards to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). However, staff sought people's consent before they assisted them with their care needs. We saw staff took time to explain to people what they were doing and people were involved in everyday decisions about their care.

We made a recommendation to the provider about capacity and best interests recording and training for staff.

Staff received support and training in order to carry out their roles. Records showed that staff had completed training in a range of areas including dementia care, health and safety, moving and handling, safeguarding adults, end of life care and infection control. However, staff had not all received training in relation to one healthcare condition. Newly employed staff members were required to complete an induction programme and work alongside experienced members of staff. Staff received appropriate support, although supervision and appraisals were not always carried out regularly.

People were receiving person centred care, although records did not always record their choices and preferences. A care plan for a person with a specific health condition was not in place. Care plans were not always updated to reflect people's changing needs. However, people told us they felt involved in day to day decision about their care and support.

We made a recommendation to the provider about person centred care planning.

People told us they felt safe at the home. Staff understood their role in safeguarding people from abuse and demonstrated knowledge of local safeguarding procedures. Staff said they felt confident the management would take action of they raised any concerns.

People and relatives spoke positively about the staff and praised them for their kindness. Staff were seen supporting people in an unrushed and pleasant manner. Staff spoke with respect about people and there was much laughter between staff and people. Staff said they enjoyed working at the home. People told us they were happy living at The Grange.

People told us there were enough staff on duty to meet their needs. We saw there were enough staff available to support people and were attentive to people’s needs and requests for assistance. Staff responded to people quickly and spent time with them individually and as a group.

Staff were recruited following a clear process which ensured risks were minimised. This included ensuring disclosure and barring service (police) checks were undertaken, and any risks identified assessed.

People told us they were encouraged to do things for themselves and staff supported them to remain independent wherever possible. People told us staff treated people with dignity and respected their privacy.

People told us they enjoyed the food. One person told us, "The meals are good and I like what we have.” Another person told us, "I like the food we have here, I am well fed." Lunchtime was a social event with people sitting together and sharing conversation. Throughout the inspection we saw people being offered drinks and snacks and staff responded to people’s requests for a drink promptly.

People were supported to access health and social care services to promote their on-going health and wellbeing, such as opticians, chiropodists and the community nurses.

People had access to a range of activities and there was an organised programme of events including bingo, reminiscence, musical entertainers, darts, games and singing. During the inspection we saw people enjoying visits from furry animals, taking part in an exercise class and group quizzes. We also saw staff spending individual time with people going through the newspaper and giving people manicures.

At the time of this inspection 14 people were living at the home and eight people were living in the supported living service, although none of these people were receiving support with their personal care needs.

The home had a registered manger 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.’

During the previous inspection in April 2015 we found there were breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We identified improvements were required in relation to care and medicine records, manual handling practices, staff’s’ understanding of the Mental Capacity Act (2005) and deprivation of liberty safeguards and staff training. At this inspection in September and October 2016 we found improvements had been made. However the documentation relating to the application of people’s topical medicines and how people were supported to use the home’s facilities safely required improvement.

While records showed people received their oral medicines as prescribed, those relating to the application of topical creams were incomplete. Where people had been prescribed creams to be applied more than once a day, these had only been recorded once, and where more than one cream was prescribed it was not possible to identify what cream had been applied at what time. The registered manager said they would remind staff of their responsibility to ensure people received these as prescribed and that records were fully completed.

Following the previous inspection, care practices in relation to assisting people with their mobility had been addressed and we saw staff assisting people and using equipment safely. However, where staff were assisting people to use the ground floor toilet facilities, we saw this posed a risk to people who required assistance to stand due to the small size of the room. We asked the registered manager to consider how people could be assisted more safely and they instructed staff to use either people’s en-suite facilities or the toilet on the first floor which was large enough for people’s wheelchairs.

Staff were knowledgeable about the people they supported and told us about people’s preferences. Care plans had been reviewed since the previous inspection. However, these were lengthy documents with information about each care topic recorded in different sections of the care files. We discussed this with the registered manager and by the second day of the inspection they had made changes to ensure the care files were more concise and easier to read. People were involved in contributing to their care plans and monthly reviews allowed people to comment about how they were being supported. Assessments of people’s capacity to make decisions about their care and treatment, or if a best interest decision needed to be made on their behalf, had been undertaken. However, while the assessments identified the decisions people were able or not able to make, the outcomes of the best interest decisions were not always documented in full. The registered manager confirmed they would ensure the outcomes of the decisions were documented with the assessments.

The registered manager had also reviewed and amended people’s risk assessments. These now provided an up to date description of people’s care needs and the management plans to reduce risks to their health and safety. The home had available the equipment necessary to support people’s care needs safely. This included specialist beds which raised and lowered and allowed for the use of a hoist as well as air mattresses to reduce the risk of pressure ulcers.

People were referred to health care professionals such as their GP, the community nurses or dieticians as needed. People also were supported by specialist nurses such as those for diabetes and respiratory conditions. Records of these referrals were maintained in people’s care files.

People told us they enjoyed living at the home and they said they felt safe and well cared for. Their comments included, “It’s lovely here” and “I feel quite at home here.” Relatives also told us they felt the staff were very kind and caring. One said, “The staff are very attentive.” Staff provided a caring and relaxed environment and throughout the inspection we heard and saw staff interacting with people in a calm and friendly manner. A programme of daily activities was planned each month. People told us they enjoyed having something to do each day. Activities included exercises to music, Tai Chi, arts and craft sessions, bingo, crosswords, singers and musicians and trips out on the home’s minibus. Church services were held every two weeks.

People had access to refreshments at all times and we saw people were regularly offered drinks. Staff told us they were able to make drinks and something to eat for people at any time of the day or night. People told us they enjoyed the food and always had plenty to eat. One person told us, “The food is very nice and always nicely presented.” Where people were at risk of not eating enough to maintain their health staff were monitoring their intake and following the guidance from the community dietician.

The registered manager, staff and the people we spoke with told us there were enough staff on duty to meet people’s needs. One person told us, “There are always staff around to help.” The registered provider and the registered manager told us staffing levels were frequently reviewed in line with people’s care needs. Staff were safely recruited and were provided with the training they required to carry out their caring role. A matrix identified when staff had undertaken training and when updates were due. Staff had received training in safeguarding adults and they demonstrated a good understanding of how to keep people safe and how and to whom they should report concerns. One member of staff said the welfare of the people living at the home was their “first and utmost priority”.

People and staff told us the home was well managed. The registered manager had a clear vision for the home, which was to provide personalised care and attention to people. There were no on-going or recent complaints in progress at the time of the inspection. People told us they had not had to make a complaint but would approach the registered manager or staff with any worries or concerns. Both the registered provider and registered manager kept up to date with current good practice within the care profession by attending forums, accessing professional websites and meeting with other care providers.

Since the previous inspection the home had been extended with a large sun room on the ground floor. This provided more communal space leading from both the lounge and dining rooms with sufficient seating and access to a pleasant and secure garden.

We found a breach 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 this report.

Systems were in place to support people and involve family members where people were not able to make decisions or give consent to care

We found that people's needs were met in a respectful and discreet manner and according to their preferences.

We saw that well written accurate care plans contained details of people's physical and mental needs. Directions for care workers on how to meet these needs were easy to follow. We saw these needs had been met.

The home was well maintained, clean and tidy. There were systems in place to prevent the spread of infection.

People were very complimentary about the stable group of care workers and described staff as 'wonderful', 'lovely' and 'very kind.' There were effective recruitment procedures in place and staff had received sufficient training, support and supervision.

The home was well managed. People, staff and visitors all spoke highly of the manager and provider.

There were effective systems in place to regularly assess and monitor the quality of the services provided. There were also well structured processes to identify and manage risks relating to the health and safety at the home.

We found that people's needs were met in a respectful and discreet manner. Care workers were able to tell us how they supported people and respected people's preferences even though they could change.

We saw that well written accurate care plans contained details of people's physical and mental needs. Directions for care workers on how to meet these needs were easy to follow. We saw these needs had been met. Medicines were well managed at the home and were securely stored.

People told us they felt safe at the home and care workers were aware of the procedures to be followed if they suspected abuse was occurring.

People were very complimentary about the stable group of care workers. One person said 'They are all lovely.'

We found that there were enough care workers on duty to meet the needs of the people who lived at the home. These staff had received sufficient training, support and supervision.

The home was well managed. People, staff and visitors all spoke highly of the manager and provider. Records reflected the management of the home. They were well maintained and securely stored.