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Inspection carried out on 20 November 2018

During a routine inspection

This inspection took place on 20 and 26 November 2018. The first day of the inspection was unannounced.

The Grange is situated close to Selby town centre and is registered to provide residential care for up to 47 people some of whom may be living with a physical disability or dementia. The service is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. At the time of our inspection 23 people lived at the service.

The service comprises of a large detached house with an additional unit called The Mews which originally supported people living with dementia. At the time of our inspection the main house was undergoing significant renovation work and everybody resided within The Mews.

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.

Staffing levels were safe. There was a registered manager and consistent team of care staff supported by a team of ancillary workers.

We have made a recommendation for the provider to review staffing levels on a weekend.

Agency staff were used to ensure safe staffing levels. Recruitment practices continued to be safe. Staff received safeguarding training and understood potential signs of abuse. Staff recorded accidents and incidents and these were monitored by the registered manager and provider. Risk assessments were completed for areas of identified risk. Staff understood the support people may require if they were distressed or anxious. Actions were taken to help control the spread of infection and to maintain the cleanliness of the service.

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’s consent was sought before providing care. There was plentiful access to food and drink throughout the day and people spoke positively about the meals. Staff undertook training and received regular supervisions and appraisals to support them in their role. People told us staff were skilled at their jobs. Efforts had been made to assist with people’s orientation around the service.

People said staff were kind and caring. Staff were patient and reassuring in their approach to people. Staff supported people to use their skills and promoted their independence. Information was available about how people communicated their needs and wishes and staff encouraged their decision making. People had access to advocacy support if they needed support to make decisions or to express their views.

Detailed and person-centred care plans were in place and these were reviewed. A timetable of activities was in place for people to participate in should they have wished to. Staff were mindful to ensure people were not socially isolated. People’s end of life wishes were documented if they had chosen to share this information.

The registered manager and provider completed a series of audits to monitor the quality and safety of the service provided to people. Staff told us they felt well supported and happy in their roles. Staff meetings were held and were an opportunity to discuss learning from the checks of the service. People’s feedback was sought on the running of the service. Statutory notifications had been sent appropriately to the Commission.

Further information is in the detailed findings below.

Inspection carried out on 12 May 2016

During a routine inspection

This inspection was unannounced and took place on 12 May 2016. The last comprehensive inspection took place on 15 April 2015 and the service was awarded an overall rating of Requires Improvement. The service was in breach of regulation 15, Premises and Equipment, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The environment was not dementia friendly. Corridors had no reminiscence information for people to look at, whilst

there was some art work on the walls there was nothing for people with dementia to engage with.

We returned to the service on 3 September 2015 and could see work had been undertaken to address these issues and the service was now meeting this regulation.

At the time of our inspection 19 people were living at The Grange.

The service had 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.

People were provided with safe care. There were sufficient staff available to meet people’s needs. Staff were recruited safely and people who used the service were involved in the recruitment process.

The service had an up to date safeguarding policy and staff understood how to identify types of abuse and who they should report their concerns to. The registered manager demonstrated a sound understanding of their role in relation to safeguarding adults.

Risk assessments and risk management plans provided staff with detailed guidance about how to prevent avoidable harm.

Medicines were administered safely. Staff had received appropriate training and the service had an up to date medicines policy based on good practice guidance.

Staff told us they were well supported and we saw evidence staff had undertaken essential training to ensure they provided safe care. The registered manager ensured staff were up to date with training and had regular supervision.

The service worked within the principles of the Mental Capacity Act and sought consent from people before they provided support. For people unable to consent to their care the service had completed mental capacity assessments and the relevant people had been consulted as part of the decision making process.

People’s nutritional needs were met and they told us the food was good. We carried out observations over the lunchtime period and found people enjoyed their meal.

The environment had been decorated and designed with the needs of the people who used the service in mind. There were areas for people who walked up and down the corridors which could offer stimulation.

The service worked with health and social care professionals to ensure people received the right support at the right time. People were supported to access routine health care such as the dentist, optician and community nursing team.

People received care which reflected their needs and was based on their individual preferences. People told us care staff ensured their dignity and privacy was met. People were supported to be as independent as possible.

Care plans contained information which provided staff with a sense of what was important to the person, they were reviewed and updated on a regular basis.

People knew how to make complaints the service had received one complaint since our last inspection and this had been investigated appropriately. People and their families provided positive feedback about the service.

The registered manager was known to people and their relatives, people told us they were confident the registered manager would resolve any issues they had. The registered manager understood their role and responsibilities and was keen to develop their own professional skills and the service.

Staff morale was good and all of the staff we spoke w

Inspection carried out on 3 September 2015

During an inspection to make sure that the improvements required had been made

We carried out an unannounced comprehensive inspection of this service on 15 April 2015. At that inspection we found a breach of legal requirements. People living with dementia were not living in a suitable environment which was a breach of Regulation 15 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Premises and Equipment.

The premises were not suitable for people living with dementia because there was no opportunity for them to interact with the environment. The doors, walls and handrails were all one colour and there was limited signage to help people be able to be as independent as possible. Parts of the service were in need of repair.

We also recommended the provider reviewed staffing levels and follow good practice in relation to the Mental Capacity Act (2005).

After the comprehensive inspection, the provider wrote to us with an action plan to say what they would do to meet legal requirements in relation to the breach.

We undertook this focused inspection on 3 September 2015, to check that they had followed their plan and to confirm that they now met with the legal requirements. This report only covers our findings in relation to that requirement. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for The Grange on our website at www.cqc.org.uk.

We found that improvements had been made to staffing levels to ensure there were sufficient staff available to meet people’s needs. The registered manager had reviewed staffing levels and now had sufficient staff to meet people’s needs. Care was delivered in a calm and kind way and was unhurried. People were able to make choices about their care and there were sufficient staff to support this.

The service had some staff vacancies which meant staff were doing additional shifts and the registered manager was delivering care. We suggested the registered manager keep this under review as it could impact on the leadership of the service.

Improvements had been made to the environment. Repair work and redecoration had taken place in a communal bathroom. Bedroom doors, hand rails and communal doors had been painted to enable people living with dementia to be as independent as possible. Some further work was planned to the environment to make it as dementia friendly as possible.

Improvements had been made to the implementation of the Mental Capacity Act (2005). We saw detailed assessments of people’s ability to make decisions. Where people could not make decisions the service had included the relevant people to ensure they made a best interest decision on the person’s behalf.

Inspection carried out on 15 April 2015

During a routine inspection

This inspection took place on 15 April 2015 and was unannounced. The last inspection took place on the 17 December 2013 and was a routine inspection; we had no concerns following that inspection. The service was meeting the regulations.

The Grange is registered to provide both personal and nursing care for up to 47 older people. The service comprises of a large detached house (which is currently not being used to accommodate anyone) and The Mews unit which is a thirty bedded unit across from the main house. The service is ten minutes’ walk from the town centre with its main transport links. There is parking on site.

The service had 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 had established their staffing levels based on information provided to head office, people told us they were well supported by staff but some relatives told us they did not feel there were enough staff on a weekend. We saw staff were busy and not able to sit and spend time with people, however, we observed people to be well cared for. We have made a recommendation about reviewing current staffing levels.

The registered manager told us the home was due to undergo an extensive refurbishment programme, they were not able to provide us with the specific details for this. Although the home was clean, we saw areas of disrepair and in the communal bathrooms we saw places where germs could harbour.

The environment was not dementia friendly, the corridors had nothing which would engage people with dementia and some people spent most of their day walking up and down the corridor. It was not easy to identify people’s bedrooms or communal bathroom facilities. The registered manager told us this would be addressed as part of the refurbishment programme. You can see the action we have told the provider to take at the back of the full version of this report.

People told us they felt safe and well cared for. The home had systems in place to record and report any safeguarding concerns and staff were able to tell us how they protected people from avoidable harm and had received safeguarding training.

People had detailed risk assessments in place and where a risk had been identified it was clear what action the home had taken to minimise this. As well as individual risk assessments, each person had a person emergency evacuation plan in place which was reviewed regularly. Accidents and incidents were reported and we could see what action had been taken.

Medicines were administered and stored safely.

Mental Capacity Assessments were completed, however, where people lacked the ability to make their own decisions it was difficult to see how the person completing the assessment had reached the decision. Best Interest decisions were recorded within people’s care plans and we could see all of the relevant people were involved in this. We have made a recommendation about the Mental Capacity Act.

Staff were well supported, they had access to supervision on a regular basis and all staff had received an annual appraisal. Staff told us they found the induction useful and then had access to on-going training.

People enjoyed the food served in the home; we saw lunch was a pleasant experience for people. all of the people we spoke to said they enjoyed the food the home provided. People had their weight recorded regularly and had access to healthcare professionals as needed.

People received good care from staff that they had a good rapport with. We saw people looked well cared for and their choices were respected. People’s relatives were encouraged to visit and made to feel welcome.

People’s care needs were assessed, and reviewed and care plans were easy to navigate.

We did not see any activity during the inspection and people and their relatives told us they would like more stimulation. The registered manager told us an activities coordinator was due to start the day after our inspection. Care staff told us they did not have time to support people to take part in activities.

Complaints were responded to and learning was shared, however, we noticed the home had the out of date complaints policy on display in the entrance.

We heard the registered manager was supportive and people felt improvements had been made since they had been in post. However, we did not think the registered manager was completing audits effectively, this was because they were scoring all audits as 100% however, we identified issues in relation to repairs required which had not been recorded.

Regular staff meetings took place as did ‘relatives and residents meetings’, so people had the opportunity to provide feedback on the home.

Inspection carried out on 17 December 2013

During an inspection to make sure that the improvements required had been made

People told us that they were well cared for and liked living at the Grange. A relative told us "The staff are really kind, caring and understanding. My relative always looks well cared for."

The home was clean and there were checks and audits in place to ensure that standards remained high.

People received their medication safely and in accordance with the prescribers instructions. We saw that improvements had been made in this area.

There were sufficient staff on duty to care for people. People told us they liked the staff. Comments include "The staff are lovely" and "Staff are fantastic."

The home had quality monitoring systems in place which meant that the views and opinions of people were taken in to account in the way the service was managed and ran. Relatives told us that they felt confident in raising any concerns. One said "The manager is very approachable. I feel able to raise any concerns."

Records were held securely and contained sufficient detail. They had been reviewed and updated since our last visit. They were held in a locked office so that only those needing to access them could do so.

Inspection carried out on 7 January 2013

During an inspection to make sure that the improvements required had been made

We visited The Grange in November 2012 and found that people were not protected against the risks associated with the unsafe use and management of medicines.

We issued a Warning Notice to ensure that improvements were made in order to protect people.

At our inspection in January 2013 we found that people living at The Grange were still not protected against the risks associated with the unsafe use and management of medicines.

Inspection carried out on 27 June 2013

During an inspection to make sure that the improvements required had been made

We visited this service because we had identified concerns about the way medicines were managed in November 2012, January 2013 and in April 2013. We had told the provider to take urgent action to improve the way medicines were managed in the home. This was to ensure people were kept safe and their health was protected.

We saw improvements in medicines handling. However medicines were still not handled safely at all times. We found the service was still non-compliant. Some people's medication had not been ordered in a timely manner, resulting in them not receiving their medicines. Medication records showed that people were still not always receiving their medications in a safe way, and as prescribed.

We spoke with four people who lived in the home but because of their complex needs they could not tell us if they felt they were being given their medicines safely and appropriately.

Inspection carried out on 3, 8 April 2013

During an inspection to make sure that the improvements required had been made

We carried out this visit to look at three outcomes where we had previously identified non-compliance in November 2012, January and February 2013.

The visit was primarily to look at some of the records and processes the service had to keep to demonstrate people were receiving safe care and that their health and well-being were being kept under review. We spoke briefly with three people who lived there, and with two visitors. All told us they (or their relative) were receiving good care. We also observed that people looked well cared for.

However whilst we saw improvements in some areas we found the service was still non-compliant to the three outcomes.

Medication records showed that people were still not always receiving their medications in a safe way, and as prescribed. Following our visit we referred two people’s medication care to the local authority for them to look at under their safeguarding powers.

We noted the service had a new quality audit (checking) system, but it was too early for the service to demonstrate whether it was running well. We will keep this outcome under close review and re-look at it at our next visit.

We noted care records were not always well completed, so did not always provide an accurate account of people’s care needs. However care workers we spoke with were knowledgeable about people’s needs and how they were to be met. We will also keep this outcome under close review and re-look at it at our next visit.

Inspection carried out on 6 February 2013

During an inspection in response to concerns

People we spoke with told us they were happy living at The Grange and received the care they wanted and needed. We observed that people looked clean and well cared for. People were smartly presented and were wearing appropriate footwear. One person told us they were ‘glad to be back home’ after a recent hospital stay.

People told us they liked the meals served to them. One person told us “My relative enjoys the food. They say it’s delicious.” The service monitored people’s weight and took action when they identified people were at risk of weight loss.

Whilst the provider followed a recruitment process there could be better record keeping to evidence discussions at interview and decisions taken. This would better demonstrate a robust process.

Care staff were very busy and mostly didn’t have time to sit and talk with people. The provider was actively recruiting more care staff so that people’s total needs could be better met.

Staff told us they were well trained and had the skills to carry out their work. They added that they were kept up to date about changes at The Grange and had the opportunity to give their views about working there.

Care records were not kept up to date, so were not an accurate record of the care people needed or received. Other records kept by the service were poorly maintained so did not demonstrate that the service was running well.

Inspection carried out on 27 November 2012

During an inspection in response to concerns

We carried out a responsive review of this service following a Care Quality Commission (CQC) inspection in November 2012, where serious concerns were identified about the way medicines were being managed at The Grange. We wanted to check whether people’s care needs were being managed properly, and whether the internal monitoring systems at the home were robust. We noted a new acting general manager was in post.

We found people living there overall were satisfied with the care they received. They said the care staff were friendly, kind and respectful. People we saw in the lounges and those who stayed in their beds looked clean and well cared for. Two visitors said they were happy with the care their relative received.

The care records we looked at indicated that people’s well-being was monitored and healthcare professional advice was sought appropriately. Care records overall provided the right information, though some of this was difficult to locate within the individual files. We noted that the new manager had made some changes to the way care was delivered to ensure a safer and more consistent service was provided. However we found the mealtime experience in the Main House could be improved.

We noted that whilst the provider had an electronic quality audit system, this had not always been well completed, nor actions followed up. Nor did we see evidence that information about the service was being analysed, to determine whether changes were needed.

Inspection carried out on 8, 14 November 2012

During an inspection in response to concerns

We visited this service because concerns about the way medicines were managed there were raised with us by the local authority safeguarding team. Inspectors visited the service on two days to inspect the medication processes, associated record-keeping and the actual medicines kept at the service.

We found the medication systems in place at the home were in disarray and people were being placed at unnecessary risk of harm because of this. Some people's medication had not been ordered in a timely manner, resulting in them not receiving their prescribed medicines.

We have asked the provider to take urgent action to improve the way medicines are managed at the home. This will ensure people are kept safe and their health is protected.

Inspection carried out on 2 October 2012

During an inspection to make sure that the improvements required had been made

We did not speak to people using the services at this visit as this inspection looked at the way medicines were being managed. We did however observe that medicines were given to people in a safe way, and that the medicines trolley was locked when the nurse left it. This ensured that those medicines were kept securely so that unauthorised people couldn't reach them.

Inspection carried out on 26 July 2012

During a routine inspection

Three compliance inspectors and an expert by experience visited the service. Although we talked with some of the people in the Main House we spent most of our time in The Mews.

We used a number of different methods to help us understand the experiences of people using the service, because many of the people living there had complex needs which meant they were not able to tell us their experiences. These included speaking with visitors, looking at the provider’s ‘Family and friends’ questionnaire results from earlier this year and carrying out a Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who can’t talk to us.

We observed that people appeared contented and happy. People looked well cared for their clothes were clean and well laundered. People appeared comfortable in the presence of the care staff who used non-verbal communication when necessary, like touch and smiling to reassure people who couldn’t easily communicate. The atmosphere overall was calm and relaxed and there was evidence that people had been involved in recent activities, which are needed in order to make one day different to another.

We spoke with four people in the Main House. Their comments included “It’s lovely here. I don’t need too much help. The staff are very kind.” Another told us “By and large the service is ok. The staff are very kind and courteous. They know what they’re doing. I feel very safe with them.” And a third added “The food here is very good. They cook it for you in the morning so it’s fresh when you come down (for breakfast).”

We spoke with the relatives of four people who all spoke positively about the care and treatment their relative received. One told us the staff were ‘welcoming and friendly.’ Another told us “I have never been in a home before, you don’t know what you need to know, but the staff have been very helpful.”

Inspection carried out on 23 November 2011

During an inspection to make sure that the improvements required had been made

We spoke with some people who lived at Brooklands Care Home. Generally people told us they were happy living at the home and thought the staff were kind and caring towards them.

Visitors said that staff were friendly and approachable and very caring towards the people they were looking after.

We carried out this inspection to assess the progress of the home in relation to meeting some compliance actions made at the previous inspection. In addition we also wanted to check staff training as some concerns had been raised with us around this The majority of time at the site visit was spent on The Mews unit.

Inspection carried out on 4 August 2011

During an inspection to make sure that the improvements required had been made

Brooklands Nursing Home has two separate areas. Whilst we primarily looked at The Mews, where people with dementia care needs live, a pharmacy inspector looked at the way medicines were managed in the Main House. People living in The Mews were not able to tell us about their experiences of living there because of communication difficulties caused by their dementia. We observed though that people looked well cared for. We also saw that staff were more available to respond to people’s needs on our second visit, when there were more staff working.

Inspection carried out on 31 March 2011

During an inspection in response to concerns

We did not speak with as many people as we would have liked as most people in the Main House were in their rooms, because the lift wasn't working. Two people we spoke with told us they were happy living at Brooklands though one didn't like having to stay in their room. They understood the reason for it though and said that staff had kept them up to date with what was happening with the lift. They said the care workers were kind and approachable. One relative said there seemed to be enough staff around whenever they visited.

We observed people's lives on The Mews. We saw that people received care appropriate to their needs from staff who demonstrated care and concern and who recognised the importance of a relaxed atmosphere, where people living there were valued and accepted.

Reports under our old system of regulation (including those from before CQC was created)