Gracefield Health Care Limited (GHC) - 31 St Domingo Grove

Gracefield Health Care Limited (GHC) - 31 St Domingo Grove is a residential care home providing accommodation and personal care to up to 6 people. The home is situated in a residential area of Anfield, Liverpool and provides accommodation across four floors. The service provides support to people with a learning disability, autistic people and people with mental health support needs. At the time of this inspection there were 6 people living at the home.

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

Governance processes were not always effective at improving the quality and safety of the service. We identified shortfalls with the system to record and analyse incidents and found care plans still contained some inconsistent, contradictory and missing information. The provider had identified some of the issues. However, there was not always a clear timescale of when these would been actioned.

Risk assessments and care plans had improved since the last inspection. However, staff were not always following the identified control measures to effectively manage periods of emotional distress.

People’s privacy and dignity was better respected. However, further work was required to improve staff culture as records showed staff did not always follow the advice of community mental health professionals to support people’s wellbeing and to reduce periods of emotional distress

The completion of food and fluid charts did not always reflect people were being supported in line with their care plans or with their recommended diets.

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Right Support: There was involvement of multiple stakeholders in the development of people’s behaviour support plans to ensure the model of care met the needs of autistic people and people with a learning disability.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Right Care: The use of restrictive practices had been minimised to ensure people were supported in a more dignified and respectful manner.

Right Culture: The culture of the service did not always focus on ensuring people received person-centred care.

The provider had improved their safeguarding systems to ensure people were protected from abuse. The provider demonstrated their clear commitment to minimising the use of restrictive interventions and we found a significant reduction in the use of physical restraint since the last inspection. The provider had invested in training for restrictive practices and positive behaviour support to ensure staff had the relevant skills to provide safer care to autistic people and people with a learning disability.

Infection prevention and control procedures were managed more effectively and we found the home was clean and hygienic throughout. Observations found that the environment was more appealing and better met people’s sensory and physical needs.

The provider had worked alongside the local authority medicines management team to improve their processes around medicine ordering, storage and administration.

The provider had improved their recruitment practices and the necessary pre-employment checks were completed before staff started working at the home. We found there were enough staff to support people.

Systems were now in place and working effectively to ensure concerns for people were escalated to appropriate healthcare professionals in a timely manner.

Records showed that people had input with their care plans and were involved in decisions about their care. People told us how they had contributed to the decoration of the premises and their own rooms.

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 inadequate (published 25 March 2022). and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made to some aspects of the service, however the provider remained in breach of one regulation.

This service has been in Special Measures since 25th March 2022. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

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 overall rating for the service has changed from inadequate to requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the well led section of this full report.

You can see what action we have asked the provider to take at the end of this full report.

The provider responded immediately during the inspection and put an action plan in place to address the concerns we identified with care plans and staff culture.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Gracefield Health Care Limited (GHC) - 31 St Domingo Grove on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to leadership and governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Gracefield Health Care Limited (GHC) - 31 St Domingo Grove is a residential care home providing accommodation for persons who require nursing or personal care to up to 6 people. The home is situated in a residential area of Anfield, Liverpool and provides accommodation across four floors. The service provides support to people with a learning disability, autistic people and people with mental health support needs. At the time of this inspection there were 6 people living at the home.

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

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems at the service did not support this practice.

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it. The service was not able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture.

Right support: There was an increased risk that people could be harmed, and restrictive practices did not fully take account of person-centred needs;

Right care: Care and support did not always reflect current evidence-based guidance, standards and best practice to meet the needs of autistic people and people with a learning disability;

Right culture: The culture of the service did not focus on ensuring people received person-centred care. There was a lack of manager oversight and there was no system in place to ensure learning from incidents.

There were ineffective processes in place to protect people from abuse or improper treatment. People were exposed to serious risk of harm as their care needs and associated risks had not been routinely assessed, monitored and mitigated. There was no manager oversight of incidents. Medicines were not managed safely. The home did not always ensure best practice guidance in relation COVID-19 was followed. Recruitment processes were not safe.

Staff did not have the training or support needed to make the human rights-based decisions that would have helped them to provide better, safer care to autistic people and people with a learning disability. There was no involvement of professionals in the development of people’s support plans or behaviour support plans. The provider did not always promote good health and wellbeing outcomes for people. People had access to local and community health services. However, people were not always encouraged to engage with these services.

The environment was poorly maintained, and some people's bedrooms were quite bare and contained minimal personal items. People’s privacy, dignity and independence were not respected, and people were not always supported to be involved in decisions about their care. Some people's communication care plans contained out of date information. Relatives and people told us action had not been taken to address on-going complaints.

People were supported to maintain relationships with people important to them. However, there was limited evidence that people were encouraged to develop relationships with people in the wider local community People’s care needs were not regularly reviewed. People were therefore at risk because staff did not have the up to date information required to meet their needs.

People were at risk of serious harm, because the service was not well-led. The registered manager was out of touch with what was happening in the service. The provider failed to share information with external organisations and professionals. Governance processes were inadequate and did not always keep people safe, protect their human rights and provide good quality care and support.

People and relatives told us that they could visit their loved ones. Records we viewed confirmed this. There were limited activities that took place inside the home. However, we saw that people accessed the community regularly to partake in activities of their choosing. People were supported by a small and consistent staff team. There were enough staff to meet people’s needs. We saw some caring interactions from staff. However, most interactions were task orientated.

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 4 September 2019).

Why we inspected

We undertook a targeted inspection to look at the preparedness of the home in relation to infection prevention and control during this period of high levels of coronavirus infections and winter pressures.

We inspected and found there was a concern with the environment and infection control practices, so we widened the scope of the inspection to become a comprehensive inspection which included the key questions of safe, effective, caring, responsive and well-led.

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. This included checking the provider was meeting COVID-19 vaccination requirements.

You can see what action we have asked the provider to take at the end of this full report.

Following the inspection, we took urgent action to ensure people were safe. We also required the provider to submit an urgent action plan to demonstrate how they planned to mitigate the most serious risks identified in this report.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to safe care and treatment, safeguarding people from abuse, consent, recruitment practices, person centred care, governance and treating people with dignity at this inspection.

Please see the action we have told the provider to take at the end of this report.

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.

Gracefield Health Care Limited (GHC) is a residential care home providing personal care for up to 6 people. At the time of the inspection 6 people lived in the home. Accommodation is provided in single bedrooms.

The Secretary of State has asked the Care Quality Commission (CQC) to conduct a thematic review and to make recommendations about the use of restrictive interventions in settings that provide care for people with or who might have mental health problems, learning disabilities and/or autism. Thematic reviews look in-depth at specific issues concerning quality of care across the health and social care sectors. They expand our understanding of both good and poor practice and of the potential drivers of improvement.

As part of thematic review, we carried out a survey with the registered manager at this inspection. This considered whether the service used any restrictive intervention practices (restraint, seclusion and segregation) when supporting people. The service used positive behaviour support principles to support people in the least restrictive way. No restrictive intervention practices were used.

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

Everyone said they felt safe and enjoyed life in the home. People led active and fulfilling lives and either accessed the wider community on their own or with staff support.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Care and support were delivered on an individual basis and the occupants of the home decided their daily routines. Care, support and activities were planned around individual likes and dislikes.

Professionals also spoke extremely highly of the home and how the home was able to support people to have excellent outcomes considering their complex needs.

Thorough recruitment and staff induction were in place to ensure that staff were suitable to work and provide support within the home.

Staff had access to training, all staff had gained or were in the process of obtaining professional qualifications.

Healthcare records were kept to high standards and staff knowledge of individuals was extremely good. This enabled staff to recognise early changes in people and early access to primary healthcare services this ensured excellent continuity of care.

A relative spoke of the exceptionally caring staff who were very obliging and did everything possible to meet people’s needs. They said, “I am more than happy about my [relative] care, other care services weren’t able to keep him safe, but they can at Gracefields”.

Any minor issues within the home were dealt with prior to becoming complaints.

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 25/01/2017).

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

There was a registered manager in post. A registered manager is a person who 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 service at 31 St Domingo Grove provides accommodation, care and support for up to six people who have a learning disability. The home is located in the Anfield area of Liverpool and it is located close to local amenities and public transport routes. At the time of our inspection there were four people living at the home.

This service was last inspected in February 2015. During this inspection we found the service was in breach of regulations relating to the safe management of medication, fit and proper persons employed, staff training, and governance. The overall rating for this service was ‘requires improvement’. The provider sent us an action plan detailing how they would meet these breaches and we reviewed this as part of this inspection. We found that the provider had taken action and improved in these areas. The service was no longer in breach of these regulations.

During our last inspection in February 2015, the service was in breach of regulations relating to the safe management of medications. This was because the procedure for managing medicines was not in line with good practice. The provider sent us an action plan detailing what action they were going to take and we checked this as part of this inspection. We found that the procedure for managing medicines had improved. Regular checks, training, and auditing were being completed with regards to medication, and medication was being stored in line with good practice. The provider was no longer in breach of this regulation.

During our last inspection in February 2015, we found that recruitment procedures were not always robust. This was because robust recruitment procedures were not always evident within staff files. The provider sent us an action plan detailing what action they were going to take, which we checked as part of this inspection. We saw that recruitment procedures had been changed and additional checks were made and recorded to ensure procedures were robust. The provider was no longer in breach of this regulation.

During our last inspection in February 2015, we found that staff did not always have the skills they needed to support people appropriately. This was because staff had not been trained regularly or engaged in regular supervision. The provider sent us an action plan detailing what action they were going to take to address this. We checked this during this inspection. We found that the provider had enrolled all new and existing staff onto a national training programme. We saw that a system had been implemented to check when staff were due updates, and this also documented when staff were due supervisions. We saw that supervisions were taking place regularly and all staff had had an appraisal. The provider was no longer in breach of this regulation.

During our last inspection in February 2015, we found that regular audits (checks) were taking place, however they were not effective. This was because they had not picked up a number of anomalies we found with regards medication. The provider sent us an action plan detailing what action they were going to take and we checked this as part of this inspection. We saw during this inspection that the approach to auditing had improved, and where errors or omissions were found, we saw that action plans had been drawn up with realistic time scales of when to address these. The provider was no longer in breach of this regulation.

Family members and people we spoke with throughout the duration of our inspection told us they felt safe living at St Domingo Grove.

Staff were aware of their role with regards to safeguarding and raising an alert if they needed to. We saw staff were trained in this subject, and it was often a topic for discussion during team meetings. We discussed a recent safeguarding incident and saw the provider had taken appropriate action.

Incidents and accidents were documented and analysed for root cause. Action plans were drawn up when any patterns emerged.

Risk assessments were in place for people which both encompassed how to manage the risk for that person and keep them safe from harm, while maximising their independence. Risk assessments were reviewed every month, and updated when changes occurred.

There were regular checks taking place on the equipment in the home, such as the fire extinguishers, gas, and PAT (potable appliance testing).

Staff were aware of their roles in relation to the Mental Capacity Act 2005 (MCA) and DoLS. We saw that appropriate applications had been made to the Local Authority for people who were required to have a DoLS in place.

Consent was well documented in people’s care plans. Where people required support with decision making we saw that a ‘best interest’ process had been followed and the outcome was well documented.

We saw that people were supported to receive a balanced diet. Menus were completed weekly and people took it in turns to go with staff and buy the weekly shop. We observed people being supported to make themselves drinks and food when they chose to with staff support. One person was being supported to follow a healthy eating programme.

People were supported by staff to attend medical appointments. We saw that staff kept a record when health care professionals visited people at the home or if people went to external appointments. We saw that any advice given as a result of these appointments was logged in the person’s care plan.

The home was well decorated with modern fixtures and fittings. People who lived at the home had helped to choose the décor of the home, and had also chosen how they wanted their rooms to be decorated. We saw that there was a ramp outside for disabled access, however there was no lift in the home, therefore people who were physically disabled could not be accommodated to live on the upper floors of the home. Also, if people who already lived at the home could no longer use the stairs due to a decline in their physical health they would have to be offered a room on the ground floor if this could be accommodated.

Our observations during the inspection showed warm and caring interactions between staff and people who lived at the home. On the day of our inspection, the service was having a Christmas party for people who lived there and their families. We saw that staff had come in on their day off to help people prepare food, set up a disco, and decorate the room.

People told us they felt respected by staff, and they were involved in their care and support. Staff were able to explain how they provided individualised support to people, based on their needs and preferences. Staff told us they enjoyed supporting the people at St Domingo Grove, and valued their relationships with them.

We saw that support plans were written in a way which focussed on the needs of the person, and not the needs of the service. We saw information such as what was important to people and what they needed to ensure their support worked was well documented and reviewed. We saw that each person had a ‘keyworker’ who would spend time updating each person’s care plans and other documentation to ensure information was accurate and up to date.

We saw the complaints procedure was displayed in the hallway of the home. There was always an easy read version of this for people who required it. There had been no complaints since our last inspection.

People and staff were complimentary about the registered manager who was also the owner of the organisation. People told us the registered manager led by example and encouraged a culture of teamwork and openness.

We saw that feedback was regularly gathered which was appropriate for the size of the service. This included regular key worker meetings with people who lived at the home as well as questionnaires which had recently been introduced.

We spoke with the manager and we looked at care records which demonstrated that the service had suitable arrangements in place for obtaining, and acting in accordance with, consent of people who used the service.

Relative's comments included:

'She has the option to do things'there's a good team round her'.

'Yes they're a lovely people'they seem to do quite a lot with her'.

There were three people who lived in the home and they had a range of learning disabilities. On the day of the inspection one of the people who lived at 31 Domingo Grove was at college and another person was unable to contribute to our inspection. We spoke to the third person who lived there and observed interaction between them and staff on duty.

We also spoke with a guardian of one of the people who lived in the home and they told us the manager always kept them up to date in relation to any issues regarding the person who lived at the home that they were the guardian of.

We asked staff what it was like working at 31 Domingo Grove and they told us:

'Staff and service user's really nice'.

'Love it, got family with autism'really like it'.

We found that people were involved in decisions about the service and the service was centred around people's individual needs.

People were well supported with their physical and emotional health care needs. People's needs were clearly reflected in their care plan and staff presented as having a good understanding of people's needs.

Systems were in place to protect people from the risk of abuse. Staff had undergone training in safeguarding and they were clear in their responsibilities to report concerns.

Staff felt well supported and appropriately trained. Communication across the staff team was good and staff were being provided with regular supervisions and team meetings.

The provider had a system in place for monitoring the quality of the service and this included asking people who used the service for their views.