Archived: Rapkyns Care Centre Also known as The Grange

Rapkyns Care Centre is located in Rapkyns Care Village, which is a community set behind a locked gate on the outskirts of Broadbridge Heath. The whole Rapkyns Care Village, which contains four care homes, is operated by Sussex Healthcare. Rapkyns Care Centre (also known as The Grange) is comprised of four lodges, each with a dining area, lounge and bedrooms. During our inspection one of the lodges had been temporarily closed.

Rapkyns Care Centre is owned and operated by the provider Sussex Healthcare. Services operated by the provider had been subject to a period of increased monitoring and support by local authority commissioners. As a result of concerns previously raised, the provider is currently subject to a police investigation. The investigation is on-going, and no conclusions have yet been reached.

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

People were not always kept safe at Rapkyns Care Centre. We found concerns with the safe management of risk for areas including behaviour that may challenge others, eating and drinking, feeding tubes, epilepsy care, skin integrity, and physiotherapy.

People were not consistently kept safe from the risk of abuse or neglect. We found issues with people not receiving their medicines when they should or receiving them in an unsafe way.

There were not enough permanent nurses or physiotherapy staff deployed to meet people’s needs safely. Infection control concerns were identified in relation to some agency nurses not having correct training to use specialist personal protective equipment (PPE). Lessons were not being consistently learned and similar issues to those highlighted at other inspections and locations managed by the provider were found at this inspection.

Staff training was not effective as some staff did not have a good understanding of some people’s conditions and the support they would need, such as autism. People’s health needs were not consistently being supported effectively. We found concerns with people’s feeding tubes, checking on people and monitoring their changing health needs.

People were not supported to have maximum choice and control of their lives and staff did not consistently 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. People had medicines crushed and other restrictions in place without having MCA assessments and best interest meetings.

People were not consistently supported in a way that upheld their dignity. We observed some poor interactions between one staff and some people. Some people had been left for long times in their incontinence pads, for up to 10.5 hours.

There was not a person-centred approach to supporting people at Rapkyns Care Centre. One person with autism was being left for long periods with very little or no staff support or stimulation. Activities were not personalised and were often group craft activities that people passively watched.

There was no evidence of continuous learning. Six regulations had been breached since earlier inspections dating back to September 2018 and February 2019. Urgent conditions CQC imposed on the provider’s registration had not resulted in improved standards of care and safety.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, 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 providing support to people with a learning disability and/or autistic people.

Despite our continuing concerns, people’s relatives were consistently positive in their praise for the service. One relative told us, “If it was not for Rapkyns [name] would not be with us. To know [name]’s in that environment I am lost for words that it means so much to us that she is safe and happy and is living instead of existing. We’ve seen what it could be like and nothing compares to Rapkyns.” A second relative commented, “Even though we’ve had [name] home every third weekend, she hasn’t been home during Covid and has remained happy. They (Rapkyns) have proceed to be a wonderful family for her.” A third relative said, “During summer [name] had to go to hospital for a visit and had to self-isolate on return…We told staff [name] loved sunbathing and next day we video called and [name] was laying with sun cream on and music plying.”

People had enough to eat and drink and the chef knew people’s needs well. People were able to move into the service or move on to other services. Staff supported an effective exchange of information by sharing care plans. There had been lots of assessments by funding authorities that had been facilitated.

There was a complaints procedure in place and any complaints were logged, responded to and resolved in line with the provider’s policy. Nobody at Rapkyns Care Centre was receiving end of life support but plans were available to people and their families who wanted them.

There had been a lot of work done to assess people’s needs around physiotherapy and to recruit to vacant physiotherapy posts. There were knowledge checks and safety huddles implemented by the new management team to try and increase staff knowledge and promote best practice, although the management team acknowledged this was a work in progress

The service was not able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture.

Right support:

• Model of care and setting maximises people’s choice, control and

Independence

The service was in private grounds in the countryside behind a locked gate. There were limited opportunities for people to access the local community. Staff wore uniforms and name badges to show they were care staff when supporting people.

The service was bigger than most domestic style properties. There were signs on the road before the service’s private drive, in the grounds and on the exterior of the service to indicate it was a care home.

Right care:

• Care is person-centred and promotes people’s dignity, privacy and human

Rights

People were not always supported safely.

People’s support was not always dignified.

Staff did not always respond in a compassionate or appropriate way when people experienced pain or distress.

Right culture:

• Ethos, values, attitudes and behaviours of leaders and care staff ensure people

using services lead confident, inclusive and empowered lives

The culture was not person centred or empowering. Staff tended to do things for people rather than with them.

The management team understood the challenges facing the service but there was significant work to do to raise safety standards and to provide good care.

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 11 September 2020) and there were multiple breaches of regulation. The service had been rated Requires Improvement or Inadequate for the last four inspections. At this inspection not enough improvement had been made we identified seven breaches of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

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 coronavirus and other infection outbreaks effectively.

You can see what action we have asked the provider to take at the end of this full 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 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 person centred care, dignity, consent, safe care and treatment, safeguarding people from harm, good governance and staffing at this inspection.

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 continue to monitor information we receive about the service until we return to visit. If we receive any concerning information we may inspect sooner.

The overall rating for this service is ‘Inadequate’ and the service remains 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 act 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 rat

Rapkyns Care Centre (known as ‘The Grange’) is a residential nursing home that provides nursing care and support for up to 41 people living with a learning disability, physical disability and other complex needs, including autism. The service is comprised of four lodges, each with their own dining area and nurse’s station. At the time of our inspection, there were 28 people living at the service. The service is based in a rural location, outside Horsham, within a locked gated site called The Rapkyns Care Site. The building is purpose built for people with disabilities and is significantly larger than most domestic homes.

Rapkyns Care Centre is owned and operated by the provider Sussex Healthcare. Services operated by the provider had been subject to a period of increased monitoring and support by local authority commissioners. As a result of concerns previously raised, the provider is currently subject to a police investigation. The investigation is on-going, and no conclusions have yet been reached.

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

We received information raising concerns about the support people received with their feeding tubes and positioning, particularly when lying in bed. We inspected the service, without giving any notice, at 07:15. We found people were at the correct angle whilst lying in bed. However, we also found that people were not having the care and support they needed with their physiotherapy.

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 Inadequate (published 11 September 2020).

Why we inspected

The inspection was prompted in part due to concerns received about people’s postural care and support with their breathing and physiotherapy needs. A decision was made for us to inspect and examine those risks.

CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. We do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

Please see the Safe section of this full report.

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

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.

Rapkyns Care Centre (known as ‘The Grange’) is a residential nursing home that provides nursing care and support for up to 41 people living with a learning disability, physical disability and other complex needs, including autism. The service is comprised of four lodges, each with their own dining area and nurse’s station. At the time of our inspection, there were 30 people living at the service. The service is based in a rural location, outside Horsham, within a locked gated site called The Rapkyns Care Site. The building is purpose built for people with disabilities and is significantly larger than most domestic homes.

Rapkyns Care Centre is owned and operated by the provider Sussex Healthcare. Services operated by the provider had been subject to a period of increased monitoring and support by local authority commissioners. As a result of concerns previously raised, the provider is currently subject to a police investigation. The investigation is on-going, and no conclusions have yet been reached.

The service was registered before the 'Registering the Right Support' guidelines were in place. However, the service was not operating in line with the values that underpin the 'Registering the Right Support' and other best practice guidance. These values include choice, promotion of independence and inclusion. These values were not always seen consistently in practice at the service.

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

Risks were not being managed safely at Rapkyns Care Centre. We identified concerns relating to risks around respiratory care, feeding tubes, epilepsy, constipation, monitoring people’s health, skin care, choking and unexplained injuries.

People had not been protected from the risk of abuse or neglect as systems to protect them were not effective. Staff had not always reported safeguarding concerns when they had witnessed incidents happen, such as people not receiving the correct care.

Staff were not deployed effectively to ensure people’s safety. At the time of our inspection, there was only one permanent daytime nurse employed. Agency nurses relied on care plans that were often inconsistent or on different systems. There was a lack of clinical oversight of nurses from the management.

Medicines were not consistently managed as safely as possible. There had been some improvements with medicines management since the last inspection in September 2019, with regard to the regarding policies concerning medicines management. Other areas required further improvement, such as protocols for ‘as and when required’ medicines.

Risks around infections were minimised. The service was clean and tidy. There were strict protocols in place to manage the risk of Covid-19 (Coronavirus) and people were safely isolated when necessary, to protect them and others.

Lessons had not been learned consistently. There had been a large number of injuries to people’s hands, fingers, feet and toes and these had not been picked up in audits or lessons learned. One person had an injury that was caused by an issue highlighted at our inspection in September 2019, and care plans had not been reviewed. Audits had not been effective in highlighting issues found at this inspection or improving the care and support people received.

As a new manager had started the week of our inspection the culture at the service was being changed during our inspection, but was not positive. Outcomes for people were not good and there were possible indications of a closed culture.

There was currently no registered manager in day to day charge of the service since shortly before our inspection. There was no deputy manager or clinical lead in post at the time of our inspection. Following our inspection, we were informed that a clinical lead had been seconded from the management post of another service. The provider's operations director had taken the role of ‘acting manager’ one day before our inspection. The provider also had a peripatetic manager based at the service. Management of the service remained ineffective and had not ensured improvements were made.

The provider had not worked effectively with all partner agencies. There had been safeguarding incidents that had not been alerted to the local safeguarding adults’ team or notified to the Care Quality Commission (CQC). Local health teams had not always been made aware of people’s changing needs or refusal of treatment.

The service had been engaging with people in regular meetings and had made plans for strengthening community links when social distancing measures are relaxed, and it is safe to do so.

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 6 December 2019). At this inspection enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating. The inspection was prompted in part due to concerns received about the effectiveness of improvements made and management of the service. A decision was made for us to inspect and examine those risks. Our last comprehensive inspection was in September 2019 where we found breaches of seven Regulations relating to person centred care, the need for consent, safe care and treatment, safeguarding people from harm, good governance, and staffing.

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

The overall rating for the service however has not changed as the provider was still in breach of regulations and not enough improvement had been made since our last inspection.

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 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 continued breaches in relation to: safe care and treatment, safeguarding people from abuse, good governance and staffing

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 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 with regular meetings, and the 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 therefore remains 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.

Rapkyns Care Centre (known as ‘The Grange’) is a nursing home that provides nursing care and support for up to 41 people with a learning disability, physical disability and other complex needs, including autism. There are four lodges each with their own dining area and nurse’s station. At the time of our inspection there were 34 people living at the service.

Rapkyns Care Centre is owned and operated by the provider Sussex Healthcare. Services operated by the provider had been subject to a period of increased monitoring and support by local authority commissioners. As a result of concerns previously raised, the provider is currently subject to a police investigation. The investigation is on-going, and no conclusions have yet been reached.

The service was registered before the 'Registering the Right Support' guidelines were in place. However, the service was not operating in line with the values that underpin the 'Registering the Right Support' and other best practice guidance. These values include choice, promotion of independence and inclusion. These values were not always seen consistently in practice at the service. For example, some people were not being supported to be as independent as they could be with their communication needs or their activities.

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

People’s relatives gave universally positive feedback about the service. Comments such as, “Every time we come [name] is always well dressed, always cleaned well presented”, and “I know that if I wasn't around [name] would be well cared for”, were typical of the positive feedback relatives gave us. However, our inspection found that people were not kept safe from the risk of harm as risks were not being safely reduced. Risks to people from constipation, epilepsy, choking, feeding tubes, and other health conditions were not being managed as safely as possible despite being raised as concerns on previous inspections

People were not being consistently protected from the risk of abuse or the risk of not receiving the correct medicines. The management team were not using past incidents effectively to reduce the risk of further occurrences.

Staffing numbers had increased so that one nurse was working on each of the four lodges but there were not enough permanent nurses working in the daytime. Only one permanent nurse, who also worked as the clinical lead, worked in the daytime. This meant that more than 80% of daytime nursing hours were being covered by agency staff who were not receiving supervision.

There were risks that people may not have enough to drink as fluid charts were not being completed accurately and action had not been taken when people did not drink enough.

Some staff competencies for tasks, such as oral suctioning to remove secretions from people’s airways, were not demonstrated and some training was missing.

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. Some mental capacity assessments were not decision specific and people who were assessed as lacking capacity around a decision did not have a best interest decision.

People did not receive person centred care. There was work underway to improve activities, but they were not personalised to people’s interests. We observed people watching craft activities being completed by staff rather than being actively supported to participate. Care plans were not personalised.

Audits and governance of the service was ineffective as shortfalls found at this inspection had not been identified or acted on. This is the fifth consecutive inspection that the well led domain has not been rated as good. This and the previous inspection rated the well led domain as Inadequate.

Staff spoke to people respectfully and used a kind approach.

The building was purpose built and met people’s needs, with wide corridors, en suite shower rooms, and ceiling hoists. People could access outside areas and were observed using the grounds. The service was clean, and the risk of infections was mitigated by a dedicated and effective housekeeping team.

Complaints were dealt with in line with the provider’s policy. People received effective care in their final days supported by local hospice teams.

The registered manager was a visible presence in the service, but staff and relatives told us they were overworked. There was no deputy manager in post and, with a lack of permanent daytime nurses, this meant the registered manager was spending a lot of their time directly supporting people and nurses rather than retaining oversight and monitoring responsibilities for the whole service.

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 Inadequate (published 2 May 2019) and there were seven breaches of regulation one of which was continued from the previous inspection in September 2018.

This service has been in Special Measures since May 2019

Why we inspected

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

Enforcement

We have identified six breaches of regulation in relation to person centred care, mental capacity, safe care and treatment, safeguarding, good governance and staffing.

We had previously imposed conditions on the provider's registration. The conditions are therefore imposed at each service operated by the provider. CQC imposed the conditions due to repeated and significant concerns about the quality and safety of care at a number of services operated by the provider. The conditions mean that the provider must send to the CQC, monthly information about incidents and accidents, unplanned hospital admissions and staffing. We will use this information to help us review and monitor the provider's services and actions to improve, and to inform our inspections.

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 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Special Measures:

The overall rating for this service is ‘Inadequate’ and the service remains 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 policy. 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 be taken out of special measures.

About the service:

• Rapkyns Care Centre (known as ‘The Grange’) is a residential care home that provides nursing care and support for up to 41 people with a learning disability and other complex needs, including autism and physical disabilities. There are four ‘units’ each with their own dining area and nurse’s station. At the time of our inspection there were 35 people living at the service.

• Rapkyns Care Centre is owned and operated by the provider Sussex Healthcare. Services operated by the provider had been subject to a period of increased monitoring and support by local authority commissioners. As a result of concerns raised, the provider is currently subject to a police investigation. The investigation is on-going and no conclusions have yet been reached.

• At the previous inspection in September 2018 we found one breach of regulation in relation to the safe use of people’s medicines. At this inspection we found this breach continued. We also found six new breaches of regulations relating to person centred care, dignity, consent, safeguarding, governance and staffing.

• The service was registered before the 'Registering the Right Support' guidelines were in place. However, the service was not operating in line with the values that underpin the 'Registering the Right Support' and other best practice guidance. These values include choice, promotion of independence and inclusion. These values were not always seen consistently in practice at the service. For example, some people were not treated with dignity and other people were not being supported to be as independent as they could be with their communication or their activities.

People’s experience of using this service:

• A number of aspects of the service remained unsafe.

• Some people were at risk as some risk assessments were not in place. Some risk assessments were in place but were not effective in reducing the possibility of harm. Staff had not taken steps to keep people safe, such as with behaviours that may challenge others.

• People were not consistently protected from abuse as incidents were not audited to effectively spot trends and reduce the risk of abuse.

• Staff had not consistently been deployed in a safe way. There were too few nurses deployed in the daytime and agency nurses struggled to cover two ‘units’.

• Learning from incidents had not been consistently implemented. Most of the areas of concern we found during this inspection, such as risks associated with health needs not being reduced and poor quality auditing, had already been highlighted to the provider following inspections of some of their other services. Local health teams had previously identified issues we found at this inspection and no improvement had been made.

• Staff did not have the necessary training they required to carry out their role, such as epilepsy training for emergency medicines, or use of the de-choker device.

• People’s health needs were not being met effectively. Areas such as constipation, epilepsy and people’s swallowing ability were not effectively managed.

• 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; the policies and systems in the service did not support this practice.

• People were not consistently treated with dignity and the language some staff used was not person centred.

• People did not always receive personalised care. Some people’s communication needs were not met in a personalised way.

• People with higher support needs did not have a consistently person-centred range of activities.

• Leadership at the service was not effective. Three previous inspections rated the well led domain as ‘Requires Improvement’. At this inspection the rating has reduced to Inadequate.

• Quality audits had not been effective in highlighting and putting right all the shortfalls we found at this inspection.

• We observed some people receiving caring and kind support by staff who knew them well.

• People told us that they liked their staff.

• People had enough to eat and drink and knew how to make a complaint.

More information is in the detailed findings below.

Rating at last inspection:

At our last inspection in September 2018, the service was rated "requires improvement" overall with a requires improvement rating in the safe and well led domains, and a good rating in effective, caring and responsive domains. Our last report was published on 5 February 2019. The service has been rated “requires improvement” in the well led domain in the previous three inspections. This is the first time this service has been rated Inadequate.

Why we inspected:

We inspected this service due to our analysis of information of concern from a variety of sources.

Enforcement:

We imposed conditions on the provider’s registration. The conditions are therefore imposed at each service operated by the provider. CQC imposed the conditions due to repeated and significant concerns about the quality and safety of care at a number of services operated by the provider. The conditions mean that the provider must send to the CQC, monthly information about incidents and accidents, unplanned hospital admissions and staffing. We will use this information to help us review and monitor the provider’s services and actions to improve, and to inform our inspections.

Follow up:

The overall rating for this registered provider is 'Inadequate'. This means that it has been placed into 'Special Measures' by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

• 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. We will have contact with the provider and registered manager following this report being published to discuss how they will make changes to ensure the service improves their rating to at least Good.

Rapkyn's Care Centre is a 'care home'. The centre is also known as ‘The Grange’, which we have referred to through the report. 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. The home is registered to provide accommodation and care for up to 41 people with a learning and physical disabilities. At the time of our visit 37 people were residing.

There was a well-established registered manager in post; however, they were on annual leave at the time of our inspection. 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 legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run. The peripatetic manager assisted us in the registered manager's absence. The role of a peripatetic manager supports registered managers in their role and moves from service to service offering advice and guidance.

Services operated by the provider have been subjected to a period of increased monitoring and support by commissioners. As a result of concerns raised about other locations operated by the provider, the provider is currently subject to an ongoing police investigation. Since May 2017, we have inspected a number of Sussex Health Care locations in relation to concerns about variation in quality and safety across their services and will report on what we find.

We imposed conditions on the provider’s registration. The conditions are therefore imposed at each service operated by the provider. CQC imposed the conditions due to repeated and significant concerns about the quality and safety of care at a number of services operated by the provider. The conditions mean that the provider must send to the CQC, monthly information about incidents and accidents, unplanned hospital admissions and staffing. We will use this information to help us review and monitor the provider’s services and actions to improve, and to inform our inspections.

At our last inspection in June 2017 we rated the service good overall. The key question is the service well-led, was rated as ‘requires improvement’. This was because the provider needed to ensure that their systems for monitoring and improving services were embedded and to demonstrate that good practice can be sustained in all key questions, is the service safe, effective, caring, responsive and well-led.

This inspection was brought forward due to information shared with CQC about the potential concerns around the management of people's care needs. This inspection examined those risks. At this inspection we found that the provider had been unable to sustain the rating of Good. Medicines were not always management safely and in line with guidance.

For the key question is the service well-led, this continues to be rated as ‘requires improvement.’ Medicines were not always being managed safely, consequently the provider has not been able to sustain good in the key question, is the service safe? We have also made a recommendation that the provider should review its policy for disposal of medicines waste.

The Grange was designed, built and registered before the guidance was published regarding Registering the Right Support and other best practice guidance. This guidance states that people with learning disabilities and autism using a service should be able to live as ordinary a life as any citizen. We found, the provider was not able to demonstrate they were working in line with the values due to the scale and design of the service. The model and scale of care provided is not in keeping with the cultural and professional changes to how services for people with a learning disability and/or Autism should be operated to meet their needs. Had the provider applied to register The Grange today, the application would be unlikely to be granted.

Staff described procedures that were in place to safeguard the people they supported. They fully understood the safeguarding policies and procedures and felt confident to raise a concern and thought they would be listened to.

Recruitment systems at the home continued to be safe and robust. There were sufficient trained and competent staff to meet people's individual assessed needs. All staff undertook an induction at the start of their employment and completed shadow shifts to fully understand their role and the people they supported. The staff were supported by the management team through on-going supervision and team meetings.

The home was made up of four lodges, using the acronym ‘CARE’. Cedar, Ash, Rowan and Elm lodge. Each lodge had a large dining/activity room, a large lounge and access to gardens. The design and layout of the building was hazard free and met the physical needs of people who lived there. All areas of the home were clean and in a good state of repair with equipment maintained. Each lodge had access to a hydro pool, two Spas’ and a computer room.

People received care that was personalised and responsive to their needs. People's needs that related to age, disability, religion or other protected characteristics were considered throughout the assessment and care planning process.

People were supported with their nutrition and hydration needs. Clear guidance was available for staff to follow when people had specific dietary needs. People spoke positively about their mealtime experiences and told us they were always offered choice.

We observed kind and caring interactions between people and staff. People living in the home and relatives praised the caring nature of the care staff and registered manager. People were supported to increase their independence and maintain strong links with their families. People were involved in planning their care. A wide range of activities were provided and included involvement and use of the local and wider community based facilities.

The registered provider had a clear complaints policy and procedure that people and their relatives were familiar with and felt confident any concerns would be listened to. 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.

The registered manager was accessible, supportive and had good leadership skills. Staff were aware of the values of the provider and understood their roles and responsibilities. Morale was good within the workforce.

There was a culture of listening to people and positively learning from events so similar incidents were not repeated.

The inspection was planned due to a previous rating of ‘Requires Improvement’ published for Rapkyns Care Centre in June 2016. However since that inspection, the service had been subject to a period of increased monitoring and support by commissioners. The service has been the subject of 14 safeguarding investigations and quality concerns by the local authority and partner agencies. As a result of concerns raised, the provider is currently subject to a police investigation. Our inspection did not examine specific incidents and safeguarding allegations which have formed part of these investigations. However, we used the information of concern raised by partner agencies to plan what areas we would inspect and to judge the safety and quality of the service at the time of the inspection. Between May and August 2017, we have inspected a number of Sussex Health Care locations in relation to concerns about variation in quality and safety across their services and will report on what we find.

Rapkyns Care Centre is a nursing home that provides accommodation, nursing and personal care to 41 adults with learning and physical disabilities. Accommodation is provided in four lodges called Elm Lodge, Ash Lodge, Cedar Lodge and Rowan Lodge, which are all on one site.

There were 40 people living in the four lodges at the time of our visit. In each house, there was a communal lounge and separate dining room on the ground floor, where people could socialise and eat their meals if they wished. The houses shared transport for access to the community and offered the use of specialist baths, a spa pool, physiotherapy, weekly GP visits, 24-hour nursing support, multi-sensory room, social and recreational activities programme and a swimming pool. There was a room allocated for using computers. This was a space for people to contact their relatives through video chat and email. People’s families could visit and stay at the centre in separate accommodation.

During our inspection the registered manager was present. 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 last inspection took place on 11 and 12 April 2016. As a result of this inspection, we identified two breaches of the Health and Social Care Act Regulations associated with how consent was sought where a person may have lacked capacity and how people were not always treated with dignity and respect. We identified one breach of the Registration Regulations due to the registered manager not notifying the Commission regarding an allegation of abuse. We also made a recommendation around how people were supported with communication as people were not helped by staff to use communication systems and to initiate communication. They relied on staff making suggestions that aligned with their wishes.

Following the last inspection, the provider wrote to us to confirm that they had addressed these issues. At this visit, we found people’s capacity to consent to care was properly considered and the home worked in accordance with current legislation relating to the Mental Capacity Act 2005 and the Deprivation of Liberties Safeguards. This included training for all staff on both subjects. We found people looked happy and were relaxed and comfortable with staff. People were supported by staff who understood their needs and abilities and knew them well. Staff were kind and caring towards people and upheld their privacy and dignity at all times. We found the registered manager had notified the Commission of reportable incidences such as alleged abuse, a medication error and serious injury. We observed people communicating with staff using their assessed communication methods resulting in positive interaction. Therefore the actions had been completed and the provider had now met those legal requirements.

Due to concerns raised by partner agencies about this service, we contacted West Sussex learning disabilities contracts team who fund people residing at the Rapkyns Care Centre. We received assurances that they last visited the service in April 2016 and the care records and risk assessments at that time met their contractual standards.

A number of audits and checks were used to check on the effectiveness, safety and quality of the service which the provider used to make any improvements. These included audits by external consultants, medicines audits and health and safety checks. The provider sought the views of people, professionals and relatives as part of the quality assurance process. The provider was working in partnership with multi agencies to ensure areas requiring improvement were acted on. For example acting on and sharing information with the adults safeguarding team to ensure people were in receipt of safe care. However, across the provider’s locations we have found variable quality and compliance and in some cases that “good” practice had not been sustained over time as a result of gaps in quality monitoring and good governance. Therefore further time and work was needed on behalf of the provider to ensure that “good” practice found at Rapkyns Care Centre at this inspection would be sustained through robust and continuous quality monitoring and support.

People’s care records showed risks to their safety were assessed and the action needed to mitigate those risks. These assessments and care plans were reviewed and updated at regular intervals to ensure people's changing needs were met. Environmental risks such as hoist equipment, wheelchairs and legionella checks were managed effectively through prompt and regular servicing.

Staff were trained in adult safeguarding procedures and knew what to do if they considered people were at risk of harm or if they needed to report any suspected abuse. People who were able to said they felt safe at the home.

Policies and procedures were in place to ensure the safe ordering, administration, storage and disposal of medicines. Medicines were managed, stored, given to people as prescribed and disposed of safely.

There were sufficient numbers of staff to meet people's needs. Staff recruitment procedures ensured only those staff suitable to work in a care setting were employed. Newly appointed staff received an induction to prepare them for their work. Staff had access to a range of training courses and said they were supported to attend training courses.

There was a varied and nutritious menu where people could make choices. Steps were taken to ensure people had adequate food and drink. People's health care needs were assessed, monitored and recorded. Referrals for assessment and treatment were made when needed and people received regular health checks. People were offered a wide range of both group and individual activities that were meaningful to them and which had a positive impact on their lives.

Each person's needs were assessed and this included obtaining a background history of people. Care plans and assessments were comprehensive and showed how people's needs were to be met and how staff should support people. Care was individualised to reflect people's preferences.

The environment of the home was appropriate for people who were living with complex disability needs. The service was well maintained, decorated and furnished in a style suitable for the people who used the service.

People had access to information on how to make a complaint, which was provided in an accessible format to meet their needs. Complaints had been investigated. Records were kept of the complaints and actions taken.

The provider sought the views of people, professionals and relatives as part of the quality assurance process. The provider was working in partnership with multi agencies to ensure areas requiring improvement were acted on. For example acting on and sharing information with the adults safeguarding team to ensure people were in receipt of safe care.

Rapkyns Care Centre is a nursing home that provides accommodation, nursing and personal care to 41 adults with learning and physical disabilities. Accommodation is provided in four lodges called Elm Lodge, Ash Lodge, Cedar Lodge and Rowan Lodge, which are all on one site.

There were 40 people living on site at the time of our visit. In each house, there is a communal lounge and separate dining room on the ground floor where people can socialise and eat their meals if they wish. The houses share transport for access to the community and offer the use of specialist baths, spa pool, physiotherapy, weekly GP visits, 24-hour nurse support, multi-sensory room, social and recreational activities programme and a swimming pool. There was a computer room. This was a space for people to contact their relatives through skype, face book and email. The service could accommodate relatives who wished to visit.

At the time of the inspection, 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.

Not all of the people who were using the service were able to tell us about their experiences. We relied on our observations of care and our discussions with staff and those people using the service who were able to speak with us.

Staff were trained and understood the actions required to keep people safe. People had been safeguarded against the risk of abuse by staff who took prompt action if they suspected people were at risk of harm. However the registered manager had failed to notify CQC and the local safeguarding team of an allegation of abuse that had been made.

The Deprivation of Liberty Safeguards (DoLS) protects the rights of people ensuring if there are any restrictions to their freedom and liberty, these have been authorised by the local authority as being required to protect the person from harm. Staff had received training with regard to the Mental Capacity Act 2005 and DoLS. However, the registered manager had failed to notify CQC of DoLS that had been authorised for individuals by the appropriate authority. CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS).

Staff had a good understanding of the Mental Capacity Act 2005 (MCA); however, this was not always demonstrated when best interest decisions had been made for people who were deemed to lack capacity.

People described staff as kind and caring. They felt they were treated with respect and dignity. Most observations reflected this. However we observed examples where staff did not treat people with respect and dignity.

Risks associated with people's care and support needs were identified and managed safely to protect them from harm. We observed staff support people safely in accordance with their risk assessments and care plans. Risks affecting people's health and welfare were understood and managed safely by staff. Environmental risks such as hoist equipment, wheelchairs and legionella checks were managed effectively through prompt and regular servicing.

People enjoyed good relationships with the staff that supported them. Staff were able to communicate with people and understand their choices. We found, however, that people were not facilitated by staff to use communication systems and to initiate communication. They relied on staff making suggestions that fitted with their wishes.

We made a recommendation around how people are supported with communication.

The behaviour of the registered manager and members of the senior management team at times did not encourage open communication. The impact of this meant the service did not always feel it had a transparent open culture.

Daily staffing needs were analysed by the registered manager. The registered manager ensured there were always sufficient numbers of staff with the necessary experience and skills to support people safely. Staff told us there was always enough staff to respond immediately when people required support, which we observed in practice.

Staff had undergone pre-employment checks as part of their recruitment. Prospective staff underwent a practical assessment and role related interview before being appointed. People were safe as they were cared for by staff whose suitability for their role had been assessed by the provider.

Policies and procedures were in place to ensure the safe ordering, administration, storage and disposal of medicines. Medicines were managed, stored, given to people as prescribed and disposed of safely. Nurses had completed safe management of medicines training and had their competency assessed annually. The nurses were able to tell us about people's different medicines and why they were prescribed, together with any potential side effects.

Staff completed an induction course based on nationally recognised standards and spent time working with experienced staff before they were allowed to support people unsupervised. This ensured they had the appropriate knowledge and skills to support people effectively. Records showed that the provider's required staff training was up to date. This training was refreshed regularly to enable and ensure staff had retained and updated the skills and knowledge required to support people effectively.

People were offered a wide range of both group and individual activities that were meaningful to them and which had a positive impact on their lives.

People were supported to maintain a healthy balanced diet through the provision of nutritious food and drink by staff who understood their dietary preferences. We observed communal mealtimes where people and staff ate together. Where people had been identified to be at risk of choking, staff supported them discreetly to minimise such risks, while protecting them from harm.

People were supported to attend regular health checks by staff that recognised when people were unwell or upset, and took prompt action to promote their health and wellbeing.

People were relaxed and calm in the company of staff who they readily approached for support or reassurance when required. Staff were attentive and responded promptly to people's needs, following their behaviour care plans.

People were supported to keep in contact with their family and friends. One relative told us they were very pleased with the sensitive support provided to their relative. Another relative told us staff ensured their relatives emotional needs were supported, whilst promoting their independence.

People had access to information on how to make a complaint, which was provided in an accessible format to meet their needs. Complaints had been investigated. Records were kept of the complaints and actions taken.

People's needs were assessed and regularly reviewed to ensure their care and support was responsive to changes identified. Care plans and regular reviews documented the support and care people required, and how this should be provided in accordance with their wishes.

Records accurately reflected people's needs and were up to date. Staff were provided with necessary information and guidance to meet people's needs. People's and staff records were stored securely, protecting their confidential information from unauthorised persons.

Systems were in place to gather people's views and these were used effectively to improve the service. Staff described the registered manager as open and approachable. They were confident any concerns would be addressed and staff and people felt listened to.

There were effective systems and processes in place to monitor the quality and safety of the service and action had been taken to respond to known shortfalls and risks.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also found a breach in Regulation 18 of the Care Quality Commission (Registration) Regulations 2009. You can see what action we told the provider to take at the back of the full version of this report.