The Grange

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to safe care and treatment, premises and equipment and fit and proper persons employed.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice. The registered manager shared knowledge and information with staff during supervisions and meetings and records confirmed this. However, the action plans completed following the meetings did not evidence how issues raised were to be addressed, dates to be achieved, if actions had been resolved or remained outstanding, and there was no formal record kept of lessons learnt. This limited the ability to learn from incidents and feedback and meant learning from good practice was not always identified or embedded across the service.

The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always make sure there was continuity of care, including when people moved between different services. We found the registered manager had not put systems in place to ensure people’s needs could be met safely when first being admitted to the service. One person’s records we reviewed had not had a care plan put in place following their admission to the service and their preadmission assessment contained limited information. We could not be assured staff would be able to meet this person needs safely.

Although the registered manager completed initial assessments, care plans were not formulated in a timely manner. This meant staff did not have access to the detailed guidance needed to provide safe, consistent and person centred care from the point of admission.

The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. The provider did not always share concerns quickly and appropriately. Safeguarding policies and procedures were in place; however, these were not always followed when safeguarding incidents had occurred. Not all safeguarding allegations had been referred to the appropriate authorities in a timely manner. Limited information was being recorded in the investigation reports. Accident and incidents were documented but there was little evidence the service used this information to learn from and prevent a similar accident or incident from occurring in the future. Feedback from a health professional stated, “A recent unannounced visit showed thatsafeguards were not alwaysreported appropriately.” A relative told us, “The home does not always inform or update us if there are any changes to [relative’s] healthcare needs. My [relative] became seriously unwell and required hospital treatment, during which a safeguarding concern was raised. I never found out the outcome.”

Staff understood how to recognise the signs of abuse and could describe the actions they would take to safeguard people. This action included informing other agencies if there were concerns about how the service was responding and what actions were being taken. A staff member told us, “I would report to my manager, and I would escalate to local authority if I needed to.”

Risks to people's safety and wellbeing were not fully assessed and recorded. Management plans did not provide enough detail as to how identified risks should be managed and mitigated. For example, there was no information available to guide staff on how to support a person with diabetes should their blood sugar levels not be within the normal range. This meant that staff may not be able to respond appropriately to changes in the person’s medical condition potentially placing them at risk of harm. A relative told us, “I have lots of concerns about [relative’s] healthcare as they have complex needs. I don’t feel the service meet them, but I don’t have any other options for [relative] to be.”

People's care plans and risk assessments were not personalised, with the information staff needed to provide support safely. A person who had epilepsy did not have a care plan or risk assessment in place to guide staff to monitor and support person safely. Risks associated with their epilepsy were not considered or documented.

Risks relating to the service’s fire safety arrangements were monitored and individual Personal Emergency Evacuation Plans (PEEPs) were in place. However, some plans contained inaccurate or out-of-date information, and for some people, a PEEP was not available on the day of the inspection. We also found that PEEPs were stored in the office, which staff could not access when the office was locked. This meant staff may not have had immediate access to essential information needed to support people safely in the event of an emergency.

Following the inspection, the registered manager confirmed they had reviewed and updated the PEEPs that were out of date and ensured these were accessible to staff.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Some areas of the premises that needed repair had not been identified and fixtures and fittings were not provided as required to help improve people’s quality of life. We found several environmental hazards, including unsecured wardrobes and drawers in people’s bedrooms. There were either damaged or poorly maintained bathrooms, rusted fixtures, mould, and unpleasant odours. For example, we found a rusted toilet seat in the downstairs bathroom, a shower cubicle with black mould and an unpleasant smell, rust on one of the bathroom shower screen, and strong odours in some of the bedrooms where the shower cubicle drains were either uncovered or dirty. Several rooms also required repainting due to scuff marks on walls. Some equipment, such as televisions in people’s bedrooms, were not functioning, and hygiene concerns were identified where personal items were unclean or stored in shared spaces.

Overall, the lack of maintenance and attention to the quality and safety of the environment meant there was a potential risk of harm to people using the environment.

Following the inspection the registered manager told us the maintenance team were making improvements where required.

The registered manager had not always ensured staff were safely recruited. We saw gaps in recruitment files, such as staff not having a completed application form containing a full employment history, incomplete interview documentation, and a reference not obtained. The registered manager did not carry out a staff file audit. This meant the registered manager could not be assured that staff were suitably skilled, qualified and safely recruited to meet people’s needs.

Although all staff had a DBS in place at the time of our inspection, the Disclosure and Barring Service (DBS) checks seen on some staff files from when they first started working had been issued by previous employers. DBS checks provide information including details about convictions and cautions held on the Police National Computer and help employers make safer recruitment decisions. This meant the provider could not demonstrate they had completed a full and robust recruitment process for all staff when they first started working.

Staff told us they were supported with an induction and were given the opportunity to shadow more experienced staff when they first started working. However, the completed induction records on staff files had not been signed off by the registered manager or staff member and did not include any information about shadow shifts, limiting assurance that staff were adequately supported when starting their roles.

There was enough staff available to provide consistent care to people safely. However, we received variable feedback from relatives. A relative told us, “There are enough staff in the daytime but not at night. At night they still care but I don’t think there are enough staff.” Another relative told us, “There are a lot of staff, but the turnover is high and they use agency a lot. The two best carers left recently, I feel I don’t have anyone on my side now. It is very concerning.”

The provider did not always assess or manage the risk of infection. They did not consistently detect or control the risk of it spreading or address concerns promptly. Several environmental hygiene issues demonstrated ineffective Infection prevention and control (IPC) oversight, including visibly dirty areasof the home, and unpleasant odours in multiple rooms.

We also found multiple toothbrushes, opened tubes of toothpaste and several used towels stored in shared bathrooms. These practices increase the risk of cross contamination between people and showed that staff were not consistently following safe IPC routines. Unclean personal items were also observed, further indicating that effective checks were not in place to ensure hygiene standards were maintained.

The registered manager completed monthly audits to monitor the cleanliness of the service. However, the audits lacked detail and the information recorded on the audit did not have any dates for actions to be completed and there were no outcomes recorded. Details of who the actions needed to be completed by were also not recorded. The daily audits did not identify the infection prevention and control shortfalls found on this inspection.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We found protocols missing in some records for medicines prescribed as when required (PRN). Protocols are important as they help staff understand when it is appropriate to offer PRN medicines. The registered manager told us they will update medication records to include a PRN protocol when we raised these concerns with them.

We found some topical creams had not been dated when opened. This meant we could not be assured these creams were being used within the manufacturer’s recommended timeframe once opened for optimal effectiveness.

We identified used out-of-date topical cream stored in a person’s bedroom. This meant routine medicines checks had not identified expired items, reducing assurance that systems were effective in ensuring only safe and appropriate products remained in use.

However, staff had received training in managing medicines and had their competency checked. A member of staff told us, “I had my medicines training, and my manager carried out observations and checked my competency.” Staff we spoke to were knowledgeable about the people in the service and their medicines needs.”