Priory Grange Care Home Limited

Priory Grange Care Home Limited is a residential care home providing personal care for up to 41 older people who may be living with dementia. The service was supporting 33 people at the time of our inspection.

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

Since the last inspection, the provider improved the quality of care records, in relation to people’s safety. Care records contained information about people’s needs and risks. People’s preferences and choices were considered and reflected within records. There were enough staff to meet people’s needs, staffing levels had improved at night to meet people’s individual needs.

Improvements to the environment had been made to ensure effective infection prevention control.

Medicines were managed safely. Staff received training and competency checks in relation to medicines.

Staff demonstrated a good level of understanding in relation to safeguarding. Appropriate referrals to the local safeguarding team had been made.

People and their relatives were involved in the service. Care was planned around people's choices and preferred routines.

People and relatives said they felt the service was safe and that people were well supported and received good quality care. The registered manager and provider were responsive to feedback and committed to improving the service. The culture of the service was open, and people felt able to raise concerns.

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.

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 22 September 2021).

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 and the provider was no longer in breach of regulations.

At our last inspection we recommended that the provider continued to review and audit record keeping relating to the safe management of medicines. At this inspection we found improvements had been embedded in the service, to ensure effective auditing and record keeping in relation to the safe management of medicines.

This service has been in Special Measures since 11 June 2021. 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

We carried out an unannounced focused inspection of this service on 14 July 2021 and 19 July 2021. Breaches of legal requirements were found. The provider completed an action plan after the inspection to show what they would do and by when to improve the safety of the care and treatment, the premises and equipment, staffing levels and their governance arrangements.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

We also 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.

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

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

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Priory Grange Care Home Limited on our website at www.cqc.org.uk.

Follow up

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

Priory Grange Care Home Limited is a residential care home providing personal care for up to 41 older people who may be living with dementia. The service was supporting 31 people at the time of our inspection.

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

People were at risk of harm, because of failures to adequately identify and address concerns about the quality and safety of the service. A new registered manager was working to make improvements, but new systems of governance were not embedded and effective in guaranteeing the quality and safety of the service. Inconsistencies remained in how risks were managed. Issues and concerns we found had not been identified by the provider's governance arrangements, and management of risks remained reactive at times. There were multiple continued breaches of regulation.

Whilst noticeable improvements had been made in response to concerns identified at our last inspection, further improvements were needed. Work was ongoing to address some concerns, and we identified new concerns, which placed people at increased risk of harm.

Significant areas of the service had been redecorated, but other areas, including bathrooms and toilets, remained in need of renovation and redecoration.

People were at increased risk as consistent standards of cleanliness had not been maintained in all areas of the service. Enough cleaners were not always on duty to ensure cleaning tasks were completed.

Appropriate window opening restrictors were not in place to minimise the risk of people falling from a height likely to cause harm. The risks associated with legionella’s bacteria in the water system had not been effectively managed putting people who may be vulnerable at risk of harm.

Adequate steps had not been taken to make sure staffing levels at night were safe. Appropriate fire drills had not been completed to check whether staff could safely evacuate people if a fire occurred at night.

The registered manager was responsive to our feedback and acted to address concerns following our site visit. For example, they arranged for appropriate window opening restrictors to be installed, addressed the legionella risk, and hired another cleaner. The registered manager continued to work with a consultant to embed a system of audits to monitor the quality and safety of the service.

Improvements had been made to how people’s medicines were managed, although we made a recommendation in relation to record keeping and auditing.

People gave generally positive feedback about the service and the care and support they received.

Staff were trained to identify and respond to safeguarding concerns. The registered manager monitored any accidents or incidents that occurred to help identify any patterns or trends. This helped to make sure appropriate action had been taken to prevent accidents or incidents reoccurring.

People felt able to speak with staff or management if they were unhappy about the service or needed to complain. Staff were observing providing kind care to meet people’s needs.

For more details, please see the full report which is on the Care Quality Commission’s (CQC) website at www.cqc.org.uk.

Rating at last inspection and update

The last rating for this service was inadequate (published 11 June 2021) and there were multiple breaches of regulation. The provider completed an action plan after the inspection to show what they would do and by when to improve.

At this inspection, we found improvements had been made, but further improvements were needed, and the provider was still in breach of regulations. This was the second consecutive inspection the service had not achieved a good rating.

Why we inspected

We carried out an unannounced focused inspection of this service on 3 February 2021. Breaches of legal requirements were found. The provider completed an action plan after the inspection to show what they would do and by when to improve the safety of the care and treatment, the premises and equipment, staffing levels and their governance arrangements.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-Led which contain those requirements.

We also 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 ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has improved from inadequate to requires improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Priory Grange Care Home Limited on our website at www.cqc.org.uk.

Follow up

We will request an action plan for the provider and meet with them following this report being published to understand how they will make changes to ensure they improve their rating to at least good. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information, we may inspect sooner.

The overall rating for this service is ‘requires improvement’. However, the service remains in ‘special measures’. We do this when services have been rated as 'Inadequate' overall or in any Key Question over two consecutive inspections. 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 six 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, 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.

About the service

Priory Grange Care Home Limited accommodates 41 people in one adapted building. At the time of inspection 23 people were living at the service. It is a two-storey building with en-suite bedrooms and communal lounges, dining rooms and bathrooms on both floors. The service provided personal care to people aged 65 and over, some of whom were living with dementia.

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

People at Priory Grange Care Home Limited did not receive a safe and well led service.

We identified significant concerns relating to people’s safety. This included poor oversight of fire safety, gas safety and safety and cleanliness of equipment. Risk assessments and regular safety checks had not been completed which placed people at risk of harm.

The provider did not have effective systems in place to monitor the quality and safety of the service. The premises were not well maintained and areas including furniture, carpets and equipment used to support people were unclean and not fit for purpose.

Staffing levels were low and had not been calculated in line with people’s needs. We observed people’s needs not being met in a timely manner. Staffing rotas were not in place. Systems were in place to recruit staff safely. However, these were not always completed effectively.

Standards of record keeping were poor and information about people’s care needs were not always recorded and communicated to staff. Staff failed to engage in a meaningful way with people and during the inspection we observed people not having their needs met.

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 in the service did not support this practice.

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 overall with requires improvement in the key question well led published 23 June 2018.

Why we inspected

We received concerns in relation to Infection control. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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 Inadequate. This is based on the findings at this inspection.

We found evidence that the provider needs to make improvements. Please see Safe and Well led sections of this full report.

You can read the report from our last inspection, by selecting the all reports link for Priory Grange Care Home Limited on our website www.cqc.org.uk

Enforcement

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

We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to fire safety and managing risks, staffing levels and staff support, failing to operate effective monitoring systems to improve the quality and safety of the service and poor record keeping.

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

Follow up

We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

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.

Priory Grange Care Home Limited 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.

Priory Grange Care Home Limited accommodates 41 people in one adapted building. It is in a residential area of the city of Hull. It is a two storey building with en-suite bedrooms and communal lounges, dining rooms and bathrooms on both floors. A small enclosed garden to the rear of the property is accessible to people via a ramp.

At the last comprehensive inspection in November 2016 the service was in breach of Regulations 9, 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At that inspection the service was rated 'Requires Improvement'. These breaches in regulations were with regard to person-centred care, safe care and treatment and good governance.

In respect of regulation 9, care plans contained insufficient detail on people’s mental health, personal care, pressure relief and nutrition. For regulation 12, risks were not managed in respect of medicines, as we found that people’s pain relief patches had not been given at the right time, medicine stock controls were ineffective, there were no protocols for ‘as required’ medicines and records kept on medicines were poor. Risks were not managed in respect of infection control as we found that hand-washing and clinical waste facilities were poor, commodes were dirty, laundry flow was ineffective, toiletries were poorly stored and equipment and furniture was dirty. Risk assessment documentation was insufficiently detailed. In respect of regulation 17, audits had failed to identify the issues found on inspection and so were ineffective.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the service delivery so that the regulations were met.

At this inspection in January 2018 we rated the service as ‘Good’.

We found improvements were made with the service in that care plans had been re-written, care was provided according to people’s assessed needs and risks, the management of risk was improved and audits were more effectively used to identify shortfalls in service delivery. Therefore the provider was no longer in breach of regulations 9, 12 and 17. However, we found that the service was without a registered manager.

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

At the time of the inspection the registered manager had just left their employment with the provider following a mutual understanding and agreement. An acting manager (who we have referred to as the manager throughout this report) was covering the vacancy, though they had taken a position as deputy manager just three months before this. A team leader was acting as the deputy manager and together they were the management team. The provider discussed the situation with us and explained that the manager would be submitting an application to register and the registered manager would be submitting an application to de-register. The provider had sent a notification to the Care Quality Commission about the registered manager’s absence. They told us they would send another because the registered manager had now left their position. However, because there was no registered manager in post the Well-led section cannot be rated better than 'requires improvement'.

People were protected from harm because monitoring systems were in place and staff were appropriately trained in safeguarding adults from abuse. The premises were safely maintained and accidents and incidents were appropriately managed. Equipment was safely used in the service. Recruitment practices were followed to ensure staff were ‘suitable’ to care for and support vulnerable people. Staffing numbers were sufficient to meet people’s needs. The manager used lessons learnt to put systems into place that guarded against similar mistakes being made.

Staff were appropriately trained, regularly supervised and received annual appraisals of their personal performance. Staff respected the diversity that people presented and met their individual needs. People’s nutrition and hydration needs were met to support their health and wellbeing. Staff worked collaboratively with other health and social care professionals. Staff supported people with their health care needs. The premises were suitably designed for and the environment was ‘friendly towards’ those people living with dementia. People’s mental capacity was appropriately assessed and their rights were protected. 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 and respected.

People received compassionate care from kind staff that knew their needs and preferences. People were involved in their care and the right to express their views was respected. The management team set good examples to the staff team with regard to attitude and approach, which provided staff with good role models. People’s wellbeing, privacy, dignity and independence were monitored and respected.

There were opportunities to engage in pastimes, activities and maintain family connections. Communication needs were assessed and met. An effective complaint procedure ensured complaints were investigated without bias. Needs with regard to end of life preferences, wishes and care were sensitively met.

Quality assurance systems were effective in that satisfaction surveys, audits, meetings and handovers ensured there was effective monitoring of service delivery, but improvements made to the service were not fed back to people, relatives and professionals. We advise that this is good practice.

Culture was open, friendly and collaborative. The manager understood their responsibilities with regard to good management and practiced a management style that was open, inclusive and approachable. The manager was committed to continuous learning around best practice and was keen to learn about and implement best practice. Good partnerships with other agencies and organisations were fostered. The manager was determined to continue with the improvements needed that they had identified.

Further information is in the detailed findings below.

All toilets and bathrooms are large enough to accommodate wheelchair users easily. Various aids and adaptations are provided around the building to assist people to remain independent and aid their mobility. Staff have access to equipment to enable them to assist people to move safely.

This inspection took place on 21 and 23 November 2016. An evening visit was undertaken on 21 November, which was unannounced. The second day of the inspection was the 23 November and was announced. The reason we undertook an out of hours inspection was because some allegations had been made that people were in bed early against their will; the outcome of this will be covered in the main section of the report. The service was last inspected December 2014 and was found to be compliant with the regulations inspected at that time.

At the time of the inspection 38 people were living at the service.

There was a registered manager in post. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have a 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 that people’s medicines were not always handled safely and they did not always receive medicines as prescribed by their GP, including some opiate based pain killers. This could mean people were in unnecessary pain due to staff not following the GP’s instruction. We also found some mistakes when staff had hand written medicine doses on the medicines administration record; this could mean that people received the wrong dose of medicines. We found there were no instructions for staff to follow with regard to administering ‘as and when required’ (PRN) medicines. This could mean that people might get too much or too little medicine.

We found that staff did not always follow good practice guidelines with regard to the handling of items, which could pose a risk of cross infection. We found that the lids on clinical waste bins did not work properly so staff had to lift these by hand and this increased the risk of cross infection. There was no hand washing facilities in bed rooms for staff to use so they had to use a communal bathroom increasing the risk of cross infection. Some of the equipment used in people’s rooms was dirty and need of a deep clean, and some personal items like tooth brushes needed cleaning. Some chairs and beds were in need of replacement or cleaning, as was some bed linen.

Risk assessments in place did not always give clear instructions to staff about how to best keep people safe, and some people’s care plans did not contain essential information about their needs. Charts used to monitor people’s welfare, for example, food and fluid intake had not been consistently completed and care plans for people’s assessed specific needs had not been completed so were not available for staff. This could mean people were at risk of not being supported safely and kept safe from the risk of harm, and that staff might not deliver the right care to meet people’s needs. These are all breaches of regulations and you can see what we have told the registered provider to do at the end of the report.

Staff knew how to recognise abuse and who this should be reported to. They had received training in this area and this was updated regularly. Staff, who had been recruited safely, were provided in enough numbers to meet the needs of the people who used the service.

Staff had been trained to meet the needs of the people who used the service and this training was updated regularly and as required. Staff were provided with opportunities to gain further qualifications and experience.

People were provided with a wholesome and nutritionally balanced diet. Their weight and nutritional intake was monitored by staff and health care professionals were contacted when required. People who had dietary needs were provided with the food they needed to keep them healthy, for example, fortified diets were provided for those people who were frail and had a poor appetite.

The registered provider had systems in place which ensured people were protected by law if they needed any support with making informed decisions. Meetings had been held to make sure any decisions made on their behalf were in their best interest.

People were cared for by staff who were kind and caring and who they had good relationships with. People were supported with dignity and staff understood the importance of respecting people’s privacy and diversity. Staff were sensitive to people’s needs and assisted them discreetly. Staff supported people to be as independent as possible and to maintain life skills, however small these might be.

People had activities to choose from and were encouraged to participate whenever possible. People spent a lot of time in their rooms but the staff ensured they were included with what was going on in the service and did not become bored, by visiting them regularly and talking and interacting with them. People’s rooms displayed personal items, which they had brought with them when they came to stay at the service.

The registered provider had a complaint procedure in place and people who used the service could access this if they wanted to raise any concerns or complaints. Others who had an interest in the welfare of the people who used the service could also access the complaints procedure. All complaints were recorded and investigated to the complainant satisfaction wherever possible. Complainants were signposted to other agencies they could contact if they were not happy with the way the investigation had been undertaken by the registered provider.

The registered manager was accessible to the people who used the service and staff. They also made themselves available to visitors and relatives. Consultation was undertaken with the people who used the service and others who an interest in their welfare; this included relatives, friends, and visiting health care professionals. Findings from these consultations were collated and action plans put in place to address any issues identified. The registered provider undertook regular visits to the service to oversee quality, practise and progress. Staff meetings were held regularly to ensure staff were kept well informed about any changes in the service or work practises. The registered manager undertook internal audits to ensure the smooth running of the service and all equipment used was serviced and repaired as per the manufacturers’ recommendations.

People's comments included, 'I am satisfied with the care and treatment,' and 'You are well looked after; if you ring the belI they are here in no time, day or night. During the night you can hear them open the door to see you are all right' A relative commented, 'It seems very satisfactory to us; they are very thorough.'

People who used the service spoke positively about cleanliness. People's comments included, 'Everything is nice and clean; they clean the toilet every day,' and 'Cleanliness is very good; they are always working, always cleaning.' A relative commented,' Her room is very satisfactory; we have no complaints about cleanliness.' A visiting healthcare professional commented, 'Cleanliness is acceptable.'

There were effective recruitment and selection processes in place. People commented positively about the staff: 'The staff are all friendly, and quite happy altogether, including the night staff.' A relative commented, 'The staff take care of anything we want.'

People knew how to make a complaint. One person told us, 'They see to niggles and I am quite happy.' Another person said, 'You just ask for one of the staff to come and see you and they would sort it out for you. I've had no complaints whatsoever.'