The Grove - Care Home with Nursing Physical Disabilities

The Grove - Care Home with Nursing Physical Disabilities is a nursing and residential home for people with physical and specialist neurological care and support needs. The service provides support to 32 people. At the time of our inspection there were 31 people using the service. Accommodation is located across two floors, with a people carrying lift in place. People had access to ensuite and shared facilities. There are large grounds surrounding the service accessible to people living at the service.

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

At this inspection we found sufficient action had not been taken in response to our warning notices served at our last inspection and the provider remained in breach of regulations, resulting in people not having their needs met safely or consistently. The provider continued to lack oversight and ability to drive improvement from the last two inspections.

We found people were still not receiving care and support to meet their needs in a consistent or timely way, by sufficient numbers of staff, particularly people who did not have 1:1 support needs. Staff told us, and rotas confirmed reviews of staffing levels were still not carried out and there were not always enough staff to meet people’s needs.

Risks in relation to the management of people's medicines remained an area of concern, and there remained concerns in relation to the cleanliness and condition of people's care environment.

People were mainly supported to have maximum choice and control of their lives, however, care records continued not to contain accurate mental capacity assessments to ensure staff supported them in the least restrictive ways possible and in their best interests; the policies and systems in the service did not support this practice. Again, inspection findings demonstrated a lack of action taken by the provider in response to the previous breach of regulation and warning notice served to ensure staff adhered to the principles of the Mental Capacity Act (2005).

We received positive feedback about the care provided from people's relatives, and overall, it was felt communication had improved since our last inspection.

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. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.

The Grove - Care Home with Nursing Physical Disabilities provided care and support to people with a learning disability, but this was not their primary support need. The service provider had implemented training and development for services to incorporate right support, right care, right culture into their practice.

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 13 December 2022). Warning notices were served, for breaches of regulations relating to safe care and treatment , consent to care and support, staffing levels and the governance and oversight of the service. The warning notices were served on 18 November 2022, with the provider needing to be compliant by 02 and 30 January 2023.

At this inspection we found the provider remained in breach of regulations.

The last rating for this service was requires improvement. and has been rated requires improvement for the last three consecutive inspections and has not been compliant with the regulations since 2018.

Why we inspected

We undertook this focussed inspection to check whether the Warning Notices we previously served in relation to Regulation 11, 12, 17, and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met. This focussed inspection covered the key lines of enquiry of Safe and Well-led. The overall rating for the service has deteriorated to inadequate.

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.

Enforcement and Recommendations

We have identified continued breaches in relation to consent to care, safe care and treatment including infection prevention and the management of medicines, staffing levels, governance and oversight of the service at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

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

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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 Grove - Care Home with Nursing Physical Disabilities is a nursing and residential home for people with physical and specialist neurological care and support needs. The service provides support to 32 people. At the time of our inspection there were 28 people using the service.

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

People were not consistently having their care and support needs met in a timely way, by sufficient numbers of staff. Risks in relation to the management of people’s medicines were identified, and we had some concerns in relation to the cleanliness and condition of people’s care environment.

We found breaches of regulations, and areas of deterioration in the standards of care and oversight of the service since our last inspection. Recommendations made as an outcome of our last inspection had not been acted on. The service had received a local authority assessment in May 2022, and some of the concerns found during their assessment remained outstanding six months later, which did not ensure people’s needs were being safely met.

We identified improvements in response to serious incidents, and ensuring lessons were learnt and changes implemented was required, alongside greater oversight and support from the registered provider to ensure people’s quality of life was consistently to a high standard.

People were mainly supported to have maximum choice and control of their lives, however, care records did not contain up to date mental capacity assessments to ensure staff supported them in the least restrictive ways possible and in their best interests; the policies and systems in the service did not support this practice.

We received mainly positive feedback about the care provided from people’s relatives, however, we consistently were told communication needed to be improved, to ensure when relatives telephoned the service or rang the doorbell these were answered in a timely way.

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. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.

The Grove - Care Home with Nursing Physical Disabilities provided care and support to people with a learning disability, but this was not their primary support need. The service provider had implemented training and development for services to incorporate right support, right care, right culture into their practice.

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 with recommendations to improve staffing and people’s access to assistive technology to improve their levels of independence. At this inspection the service remains rated as requires improvement, we found breaches of the regulations, and the previous recommendations made had not been met.

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.

The inspection was prompted in part due to concerns received about environmental risk management and medicines management following serious incidents. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service remains rated requires improvement based on the findings of this inspection. We have found evidence that the provider needs to make improvements.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Grove - Care Home with Nursing Physical Disabilities on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to provision of safe care including the management of people’s medicines, cleanliness and infection prevention and control practices within areas of the care environment, assessment and review of people’s mental capacity, staffing levels and deployment and the governance and oversight of the running of the service.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

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

The Grove is a residential care home providing personal and nursing care. The service can accommodate up to 32 people in one adapted building, including those with physical disabilities and who need specialist care due to complex health conditions. At the time of our inspection there were 27 people living within the service.

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

Frequent changes in registered managers over the last five years had resulted in a deterioration in the leadership and oversight of the service. The registered manager appointed in June 2020 had resigned and was not currently working in the service. The service was being managed by a regional support manager until a new manager was appointed. The lack of leadership and support for staff had resulted in low morale and led to a blame and bullying culture amongst the staff team. The reduction in staff numbers by the provider, staff leaving and not being replaced had led to staff feeling stretched to provide people’s care. The increased use of agency staff, not so familiar with the needs of the people using the service, had added additional pressures to staff when coordinating people’s care.

We have made a recommendation about staffing.

The provider had a quality assurance framework in place to assess and monitor the service. However, these systems had not been used effectively at provider or registered manager level to identify issues we found regarding infection control practices, the impact in decreased numbers of staff and issues of a bullying culture amongst the staff team. Additionally, communication about changes in the management and staffing was not always shared with people, their relatives and staff in an open and transparent way. The quality improvement team had not been able to visit the service regularly during COVID-19 and acknowledged the service had been through a difficult time. They had arranged to carry out a full review of the service to identify and address the underlying problems in the service.

Equipment to promote people’s health and welfare, such as hoists, and suction machines were safe and fit for purpose. Technology was used to promote people’s safety, however further work was needed to ensure people with disabilities, or limited mobility had maximum choice and control of their lives and supported in the least restrictive way possible and in their best interests.

We have made a recommendation about use of assistive technology to promote people’s independence, choice, and control.

We were somewhat assured that the provider had good infection prevention and control measures in place. Staff were not always using personal protective equipment (PPE) effectively and safely. Nor were they consistently following correct hand hygiene procedures or the provider’s guidance for the use of face visors. Additionally, the practice of placing clean items on handrails and stair banisters increased the risk of them becoming cross contaminated. Senior management were in the process of addressing these issues through staff meetings, supervision and carrying out staff competencies.

We have signposted the provider to resources to develop their approach.

People’s relatives told us staff were kind and caring. We saw staff were intuitively providing care in line with the values of the company, but they were not clear about what the service’s vision, values and goals were.

Staff had a good understanding of safeguarding processes to keep people safe and how to report concerns. People told us they received their medicines when they needed them. Risks to people had been identified and manged well, including those risks associated with mobility, skin, choking, hydration and care of feeding tubes inserted directly into a person’s stomach. A thorough recruitment process was in place, which ensured staff recruited were suitable to work with people who used the service.

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 24 December 2018).

Why we inspected

The inspection was prompted in part by notification of a specific incident, following which a person using the service died. This incident is subject to a criminal investigation. As a result, this inspection did not examine the circumstances of the incident.

We also received concerns in relation to the management of people’s medicines and nursing care needs. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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 reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

We found no evidence during this inspection that people were at risk of harm, however we have found evidence that the provider needs to make improvement. Please see the safe and well led sections of this full report.

At our last inspection we rated the service good. At this inspection we found the evidence continued to support the rating of good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

The people who lived at The Grove had a wide variety of needs and health conditions and complex physical disabilities. Some people required more significant support than others and most were wheelchair users. The people who lived in The Grove were provided with high quality, safe, caring, person centred support which was responsive to their needs. People received personalised support and there was a clear understanding of seeing each person as an individual, with their own social needs.

Staff received training in all areas relating to people's individual health needs and holistic

activities. Staff also received support from external healthcare professionals on how to best care for people. People were encouraged to socialise and pursue their interests and hobbies.

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 were involved in all aspects of their care and were supported by staff to communicate their wishes, likes, dislikes and decisions. People were supported through the use of verbal communication, pictorial forms and electronic aids.

People were protected from risks relating to their physical and mental health and possible abuse. Risks to people had been assessed and had taken action to seek guidance and minimise identified risks. Staff knew how to recognise possible signs of abuse.

Staff and volunteers treated people with respect and kindness. There was a warm and pleasant atmosphere at the home where people and staff shared jokes and laughter. Staff knew people and their preferences well. People were supported to have enough to eat and drink in ways that met their needs and preferences. Meal times were social events and people were supported individually to ensure their specific needs around food and drink were met.

Staff supported people to take their medicines safely and staffs' knowledge relating to the administration of medicines was regularly checked. Staff told us they felt comfortable raising

concerns.

There were systems in place to assess, monitor and improve the quality and safety of the care and support being delivered.

Further information is in the detailed findings below

The Grove provides residential and nursing care for younger adults with physical disabilities. Accommodation is over two floors and 25 of the 32 rooms have en-suite facilities. Rooms are spacious and fully accessible. Communal areas include a number of lounges, dining rooms and those dedicated to leisure activities such as a therapy room and IT room. At the time of our inspection, 30 people were living at The Grove.

There was a manager in place who had been appointed in November 2015. At the time of the inspection, the manager had submitted an application to the Care Quality Commission (CQC) to become a registered manager; their application was being processed. 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 received care and support from staff that had received training to meet their individual needs. Staff had received comprehensive inductions that allowed them time to get to know the people they supported. Staff had been recruited following appropriate checks that showed they were safe to work in health and social care.

There were enough staff to meet people’s individual needs and they worked in a way that contributed to the smooth running of the service. Staff worked well together and supported each other. Good teamwork was evident and people had confidence in the staff that supported them.

People were complimentary about the staff that supported them. They told us they were friendly, kind and supportive. They told us staff knew them well and had time to talk with them. The relatives of people who used the service told us ‘nothing was too much trouble’ for the staff in caring for their family members.

The people who used the service told us they felt respected, valued and listened to. They had choice in their day to day living and their independence was promoted. Confidentiality and privacy was adhered to.

People were protected from the risk of abuse as staff understood their responsibilities to raise any concerns they may have. They could identify potential signs of abuse and they knew how and where to report these. We know from the information we hold about this service that concerns had been reported appropriately in the past.

The service had identified and managed the risks to the people who used the service, staff and visitors. These had been reviewed regularly to ensure people were protected from the risk of harm. Medicines had been managed and administered appropriately although some records were not entirely legible. The manager told us they would address this swiftly.

The Care Quality Commission (CQC) is required to monitor the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and report on what we find. The service had worked within the principles of the MCA and made appropriate applications for consideration of depriving some people of their liberty. Where the service had made best interests decisions for people they supported, this had been done legally and involved the appropriate people. These decisions had been recorded.

The people who used the service, and their relatives, told us they had been involved in the planning of their care and support. We saw that people’s needs had been identified and, in most cases, comprehensively recorded to ensure they received the right support. Care plans were person-centred and focused on the individual including what was required in order to achieve positive outcomes. Personal details were recorded to aid staff in getting to know people better and in order for them to develop important relationships with the people they supported.

The service ensured people had opportunities to engage in their interests and hobbies. People told us their leisure and social needs were met. With the help of a number of volunteers, the service offered a number of events and activities both inside and outside of the home. All activities and communal areas were accessible and contained leisure equipment that was stimulating.

People had access to a number of healthcare professionals to meet their health and wellbeing needs. The service worked regularly with other professionals and we saw that referrals were made promptly and appropriately. The healthcare professionals we spoke with prior to our inspection spoke highly of the service delivered at The Grove.

All the people we spoke with, and the staff, felt the management team was accommodating, empathetic and responsive to their needs. They told us they saw them regularly. An open, honest and transparent culture was encouraged and incidents were discussed in order to learn from them. Although no one we spoke with had had the need to complain, they told us they felt confident any concerns would be addressed as required. People were encouraged to continually provide feedback on the service and make suggestions.

The provider had an overview of the service being delivered and the quality of the service was monitored on a regular basis. They provided regular support to the home and undertook their own inspections to ensure a good quality and consistent service was delivered. Any findings were used to improve the experience for people who used the service.

Is it effective?

This inspection established that significant improvements had been made. We were satisfied that the manager's action plan had been fully implemented. Systems were in place to ensure that staff received the appropriate support within the timescale required by the provider's policies. Consequently, the service was effective in ensuring that people were cared for by staff who received suitable and timely support and development from the service's management team.

You can see our judgement on the front page of this report.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

This is a summary of what we found-

Is the service safe?

People told us they felt safe and were well treated by staff. They told us that staff always spoke to them respectfully. Staff had received extra information about how to safeguard the people they supported and the importance of reporting any concerns promptly to the local safeguarding team.

Systems were in place to make sure that managers and staff learnt from events such as accidents, incidents and complaints. This reduced the risks to people and helped the service to improve.

The home had proper policies and procedures in relation to the Mental Capacity Act 2005 and how to support people to make decisions about their care. Where staff thought people could not understand information and make informed decisions, appropriate processes were followed to assess their capacity and ensure decisions made were in people's best interests.

Is the service effective?

There was a residents' committee at the home, which met regularly and could help represent the views of people living there.

People's health and care needs were assessed with them, and they were involved in developing their plans of care. One person told us, 'They've just been round to talk to people about their care plans.' Specialist dietary, mobility and equipment needs were identified in care plans where required.

Staff received training to help them understand and meet people's needs appropriately. They were able to tell us clearly about people's needs and how they were supported.

Is the service caring?

People told us they felt that staff were kind. One person said, 'I have no complaints about staff. I'm very happy with the way I've been treated.' Another told us, 'Staff ask before they do things.'

Comments from relatives about the service included, 'I think the people who look after this home are lovely, lovely people.' They went on to say that they did not worry about leaving their relative in the home because the person was in 'such kind hands.' Another commented that, 'Nothing is too much trouble.'

People using the service, their relatives, friends and staff had the opportunity to complete a survey so that the manager could see if anything needed to improve.

Is the service responsive?

People were able to join a range of activities in and outside the service regularly if they wanted to. The home had adapted transport so that people could get out and about in the area. One person told us who they had a shopping trip booked because they needed new clothes. People told us about the activities they got involved in, including quizzes and learning how to use the computer.

One person told us how the service had responded when their needs changed. They said, "I need more help now and I get it."

People knew how to raise concerns if they were unhappy. One person said, 'Mostly people can raise concerns for themselves. They don't always do it through the residents' committee. People are listened to.' People commented about the residents' committee and felt that the service responded to their suggestions. They said, 'Some suggestions are taken up quickly. Some take a bit longer.'

Is the service well-led?

The service had a quality assurance system. They were participating in the Commissioning for Quality and Innovation process under the NHS, to return information about things that may indicate poor or good care so they could be sure of their standards.

Staff had a clear understanding of their roles and responsibilities and of the needs of people living in the home. This helped to ensure that people received a good quality service at all times. Staff would benefit from improved support from more senior staff, through supervision and appraisal so that they could develop further in their roles. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to supervising and appraising members of staff.

If you wish to see the evidence supporting our summary please read the full report.

People were offered drinks regularly on what was a hot day. One person said, "They come round regularly with drinks or you can ask for one." They told us that the meals were good and they enjoyed their food. We noted that a menu displaying options for lunch and tea on the day of our visit was displayed in a dining area. People receiving nutrition and fluids via tubes were given this to ensure they were properly nourished and hydrated.

Although the provider had taken steps to identify the possibility of abuse, we were concerned that allegations were not always responded to appropriately.

Checks upon staff for their suitability to work with vulnerable people were made and recruitment processes helped contribute to people's safety. However, staff did not always receive supervision and appraisal as expected, to discuss their work and any development needs and to show that they were effectively led.

People able to speak with us and relatives, told us who they would speak to if they had any concerns about the standard of care they received. They said they felt confident that any such concerns would be addressed.