Archived: St Cross Grange

St Cross Grange Care Home is a residential care home and provides care for up to 64 older people aged 65 and over. at the time of the inspection, some of whom were living with dementia or other cognitive impairments. At the time of the inspection, there were 41 people using the service.

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

Incidents and accidents were fully investigated and learning had improved practice. The introduction of a tracker enabled the registered manager to have oversight.

The provider deployed staff according to their skills and experience to meet people’s needs in a timely way.

The storage and recording of medicines had been improved to ensure people were receiving their medicines. Risks were appropriately managed.

Activities were constantly being improved and bespoke training had been provided for staff so they could consider the activity needs of people living with dementia when planning activities.

Governance systems were effective in ensuring improvements were embedded.

The adaptation, design and decoration of the building considered the needs of people living in the home. There was an ongoing refurbishment programme.

People told us they received appropriate care and support with their nutritional needs.

Relatives told us complaints were dealt with appropriately.

Suitable arrangements were in place for the management, supervision and appraisal of staff.

The provider had suitable infection control procedures.

Staff felt supported by the registered manager and told us the they had improved the service since the previous inspection.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

We last inspected the service on 20 November 2018 and rated the service ‘requires improvement’.

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.

St Cross Grange is a ‘care home’ and is registered to accommodate up to 64 people. 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. At the time of the inspection 44 people were accommodated at the home.

At our last inspection on 10 and 11 April 2018, we found four breaches of regulations. The provider did not identify and take action to reduce risks to people. The provider did not have enough staff to keep people safe, or support staff through supervision and training to ensure people were cared for by staff who had the right skills and competencies. The provider had failed to ensure people’s on-going care and treatment was planned and addressed in line with peoples changing needs. The provider did not have an effective system in place to monitor and assess the quality of the service provided in order to take action where necessary to address and rectify any shortfalls.

During this inspection we found action had been taken and improvements made for supporting staff and people’s on-going care and treatment. However, further work was required to identify risks and keep people safe and ensure people’s records were consistent and up to date. We have identified two continuing breaches in respect to this.

The Registered manager left shortly after the last inspection and there was a new manager in post who wasn’t yet registered but was in the process. 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.

We found people’s safety was compromised in some areas. Risks associated with people’s care had not always been identified or assessments made to reduce these risks for people. These included those associated with behaviours which may be challenging or distressing for people.

Relevant recruitment checks were conducted before staff started working at the service to make sure staff were of good character and had the necessary skills. However, there were unexplained gaps in some staff employment histories.

Staff received more frequent support and one to one sessions or supervision to discuss areas of development. They completed more training and felt it supported them in their job role.

Staff understood safeguarding procedures to keep people safe. There were enough staff to keep people safe.

There were plans in place for foreseeable emergencies and fire safety checks were carried out. However, a legionnaires water risk assessment had needed to be reviewed since 2016.

People’s rights were not always protected because staff did not always understand and work within the principles of the Mental Capacity Act 2005. These were in the process of being reviewed.

Medication administration records (MAR) confirmed people had received their medicines as prescribed.

People received varied meals including a choice of fresh food and drinks. Staff were aware of people’s likes and dislikes and went out of their way to provide people with what they wanted.

People were cared for with kindness, compassion and sensitivity. Care plans provided information about how people wished to receive care and support. This helped ensure people received personalised care in a way that met their individual needs.

People were supported and encouraged to make choices and had access to a range of activities. A complaints procedure was in place.

This is the second consecutive time the service has been rated Requires Improvement. The service is not yet consistently providing good care. We found two continuing breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

The home provides accommodation and personal care for up to 64 older people, some of whom live with mental health problems or dementia. Accommodation is arranged over three floors with stair and lift access to all areas. At the time of our inspection 55 people lived at the home.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

During our inspection we found there was a lack of effective management and leadership in the home. Communication was not always open and transparent in the management of the home and areas of concern we had identified during our inspection had not always been identified by the governance processes in the home.

Whilst there were safe recruitment practices in the home, there were not always sufficient staff deployed in the home to meet the needs of people.

Risk assessments had not always been completed to support staff in mitigating the risks associated with people’s care, including those associated with falls and behaviours which may be challenging or distressing for people. Care records were not always up to date to ensure staff had information on how to meet people’s needs. This was of particular importance with the use of agency staff in the home.

People did not always receive care which was person centred and responsive to their individual needs.

Systems were in place to support staff in recognising and reporting any signs of abuse. The registered manager worked closely with the local safeguarding authority to address any concerns.

People were cared for in a kind and empathetic and most staff knew people well. There were meaningful activities and interactions in the home to reduce the risk of social isolation for people.

Where people could not consent to their care, staff had sought appropriate guidance and followed legislation designed to protect people’s rights and freedom.

There was a system in place to allow people to express any concerns or complaints they may have.

People enjoyed the food they received foods in line with their preferences and choices.

The home was clean and maintenance was completed in a timely way.

At this inspection we found four breaches of the Health and Social care Act 2004 (Regulated Activities) Regulations 2014. You can see what action we have told the registered provider to take in the full version of the report.

The Glade is a ground floor unit where people who live with more complex needs related to their dementia are supported. There are three other areas of accommodation for people; the Yellow Floor, on the second floor of the home, is divided into North and South areas and the Lilac Floor on the third floor of the home. Throughout the home are communal areas both indoors and outdoors for people to use. These include dining areas, outdoor conservatories, veranda and lounge areas. At the time of our inspection 47 people lived at the home and one new wing on the ground floor of the home was not occupied.

At the time of our inspection a registered manager had not been in post since March 2017. 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. A new manager had been employed at the home since June 2017 and had begun the process to register with the Care Quality Commission as the registered manager for the home.

Whilst care plans were person centred, these were not always up to date and an accurate reflection of people’s needs. The manager had identified this concern through an audit of care records prior to our inspection and was addressing this matter.

People were supported effectively to make decisions about the care and support they received. Staff followed appropriate guidance and legislation designed to protect people’s rights and freedom although records on these matters required improving.

The risks associated with people’s care had been identified and assessments made to reduce these risks for people. People received their medicines in a safe and effective manner and the risks associated with medicines were clearly documented.

There were sufficient staff deployed to meet people’s needs and ensure their safety and welfare. However the layout of the home meant the manager was constantly reviewing staffing levels to ensure people’s safety and welfare and a recruitment drive was on-going. Staff were assessed during recruitment as to their suitability to work with people.

People were supported by staff who had a good understanding of how to keep them safe, identify signs of abuse and report these appropriately. Safeguarding concerns which were reported to the local authority had been investigated and learning outcomes from these shared with staff.

People said staff were caring and had a good understanding of how to meet their needs. Staff cared for people in a kind and empathetic way. People were supported to participate in a wide variety of activities and events. Staff and people who lived at St Cross Grange welcomed people from the community into their home.

People received nutritious food which was well presented and in line with their needs and preferences.

People were able to express their views and be actively involved in their care planning. A system was in place to allow people to express any concerns or complaints they may have and these were dealt with appropriately.

This home was rated good at our last inspection and remains good. However some work was required to ensure accurate and up to date records were maintained in the home.

The provider, Greensleeves Homes Trust Limited, sent us their action plan and advised us they had achieved compliance in the areas where we had served warning notices on 15 July 2014.

We visited St Cross Grange on 15 and 19 August 2014. Our inspection team included a pharmacist and a specialist advisor. We reviewed 12 people's care records and spoke with the new manager and 12 staff members. We also spoke with four people using the service or their relatives and two health and social care professionals.

We set out to answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, discussions with people using the service, their relatives, the staff supporting them and looking at records.

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

Is the service safe?

The staff and managers had received further training in procedures for safeguarding vulnerable adults and appropriate referrals had been undertaken since our last visit. Further training on Hampshire County Council's specific safeguarding practices was booked.

Systems for recording accidents and incidents were in place and some trend analysis had been undertaken. Further work was planned to implement an audit system to promote continuous learning and development.

The management of medicines had improved since our last visit, with more accurate administration and more suitable storage arrangements. There were aspects of medicine handling which were not safe however and still needed to be addressed.

Recruitment procedures had been reviewed and a robust system was in place to check that recruits were safe and suitable to work at the home.

Although improvements had been made to the safety of the service, we have asked the provider to tell us what they are going to do to continue with their safety improvement plan in relation to medicines managements.

Is the service effective?

We found that people's health and care needs were assessed and were reviewed more regularly. Specialist advice had been sought and followed and the service collaborated effectively with health and social care services. Analytical tools were applied correctly to assess people's care needs. Care was personalised and people were provided with the correct equipment.

Further work is required to develop personalised behaviour and emotional support plans and to ensure people on specific diets have dietary care plans and are offered appropriate choices. We have asked the provider to tell us what they are going to do to continue with their improvement plan in relation to care planning and risk assessments.

Is the service caring?

We observed staff interaction with people who lived at the home and saw this was caring, compassionate and kind. Staff were attentive and spoke with people in a friendly and appropriate way. People told us they were happy living at the home.

Is the service responsive?

We received positive feedback from staff and relatives that the new manager of the service responded to their concerns appropriately and in a timely way. Communication had improved in the home which meant staff sought medical advice promptly when people's health deteriorated.

Care plans were not always updated to reflect people's changing needs, but this had improved since our last visit.

Is the service well led?

Since our last visit the provider had employed a new manager for the home and had implemented an extensive improvement plan. The plan included the recruitment of additional care and managerial staff, which was still underway when we visited. Without the full complement of staff, there had been delay in completing and embedding some improvements within the service.

The new manager had a clear understanding of the changes that were required, what to prioritise and how to lead and support the staff team. Staff recognised that improvements were taking place. A clear management structure was planned for the service, with allocated responsibilities and management support.

Below is a summary of what we found. The summary is based on our observations during the inspection, discussions with people using the service, their relatives, the staff supporting them and looking at records. This inspection was initiated in response concerns raised from a number of different sources.

The people using the service are elderly and some have limited mobility and/or dementia. St Cross Grange has a dementia wing, known as The Glade, and other people live in Cathedral Lodge and The Wessex. These two areas are sometimes known as the Residential wing.

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

Is the service safe?

Safeguarding procedures were not robust. An incident of alleged abuse had not been managed safely to protect people until prompted by our visit.

Systems were not in place to ensure management and staff learnt from events such as accidents and incidents, complaints, concerns and investigations. This increases the risk of harm to people and fails to ensure that lessons are learned from mistakes.

The management of medicines was unsafe, as the systems for administering, recording and storing medicines were not robust. This put people at risk of harm.

Some recruitment checks into applicants' qualifications, experience and background were not being carried out. This put people at risk of being supported by staff who may not be suited to their role.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to safeguarding vulnerable people from abuse, medicines management, staff recruitment and monitoring risks and learning from incidents and events.

Is the service effective?

People's health and care needs were not assessed, reviewed and updated. Specialist nutritional advice was not always used to inform people plan of care. Where specialist advice had been sought, it was not always followed. Care planning was not always based on the correct use of analytical tools. When people's health deteriorated this was not identified quickly to ensure their care were met with clinical guidance. Care plans were therefore not able to support staff consistently to meet people's needs.

Where the provider had assessed that people were not able to make their own decisions, this was not carried out in line with legislation.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to assessing people's needs and assessing their mental capacity.

Is the service caring?

People were supported by friendly staff. We saw that care workers had a caring attitude when supporting people. However, there staff did not spend much time with people individually and we observed staff were task orientated.

Some relatives had raised concerns about the service but these were not being addressed effectively. People were at risk of not having their concerns and needs properly taken into account.

We have asked the provider to tell us what improvements that will make in relation to co-operating with other services.

Is the service well-led?

The provider did not have a robust approach to quality assurance. Shortfalls in quality identified through investigations, audits and manager visits were not effectively addressed. The service does not have a registered manager and there have been many management changes over the past three years. Staff report that they do not feel supported, and they feel overworked and lacking in clear guidance.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to quality assurance and supporting staff.

When we visited in July 2013, we met the new manager who had been in place for six weeks and we reviewed progress against their action plan. We found that the areas of concern had been addressed or were in progress. People using the service and staff were positive about the improvements and praised the new manager's approach. We observed that the premises were suitably finished and furnished, making the service more homely than it had been when we had visited previously.

Arrangements were in place to identify and monitor risks and communication had improved. People using the service were also more involved in decisions about changes within the home.

Overall, we found that the service was not compliant with nine essential standards. Four of these related to the quality of management and we found that the provider's lack of effective communication and leadership had made a negative impact on the way people were cared for, kept safe and involved in decision making.

People using the service had not been fully involved in decisions relating to the building work, and complaints had not been responded to. People had been moved out of their rooms to new accommodation when the new building was not ready to be occupied. Procedures were not in place to identify and rectify problems in a systematic way. People said 'All the staff are brilliant' yet we found that some aspects of people's care were not carried out.

People were not always kept safe. There was no assurance that builders working in the home had been checked by the Disclosure and Barring Service and some key fittings were not in place.

Staff had received training and supervisions, but relatives and staff said many staff had left. They said there were not enough staff.