The Grange

The Grange accommodates up to 25 people with a learning disability and/or autistic people. People living at the service may also have mental health conditions. People lived across four schemes. These schemes are The Grange, The Courtyard, Priddy Farmhouse and Meadowlands. People have their own apartments with en-suite facilities. Within the services there are some communal areas and The Grange has a separate group kitchen. All of the services are on a working farm site and there are day centre opportunities for people to participate in farm activities. At the time of the inspection there were 25 people living at the service.

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

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 statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

At our last inspection we found the service was not able to demonstrate how they were meeting all of the underpinning principles of Right support, right care, right culture. At this inspection we found some improvements had been made.

Right Support:

People received care and support in a safe and clean environment. Maintenance to the environment was ongoing. There were some improvements to people being able to pursue their chosen interests and achieve their aspirations and goals. Staffing arrangements were being reviewed by the provider. Although the home was reliant on agency staff, the staff knew people well. People were supported to have maximum choice and control of their lives and staff supported in the least restrictive way possible and in their best interests; the policies and systems in place supported this practice. Staff did everything they could to avoid restraining people. The service recorded when staff restrained people, and staff learned from those incidents and how they might be avoided or reduced. People had a choice about their living environment and were able to personalise their rooms.

Right Care

Some improvements were required to ensure people’s risk assessments were regularly reviewed and updated. People’s medicines were managed safely. People received care from staff that had been through a recruitment process. Staff were caring in their approach towards people. Staff understood how to protect people from poor care and abuse. The service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.

Right Culture

Systems in place to monitor the quality of the service had overall improved. Action plans were in place and some of the schemes had made more progress than others. There were still a high number of staff vacancies, the provider used regular agency staff to aid consistency. The provider was reviewing staffing so it could be planned and organised to meet people’s current needs. Permanent and regular agency staff knew and understood people well and were responsive to their needs. People’s quality of life was enhanced by the service’s culture of improvement and inclusivity.

The geographic location of the service was isolated. There were limited public buses available to transport people to the local towns and community facilities if they wished. The service had vehicles available at each scheme, however people told us there were not always drivers available.

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 19 September 2022).

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 in relation to safe care and treatment, staffing levels and good governance.

At our last inspection we recommended that the provider reviews people’s capacity assessments in line with the principles of the Mental Capacity Act 2005. At this inspection we found the provider had made improvements and they were in the process of reviewing people’s capacity assessments.

This service has been in Special Measures since 28 July 2022. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We carried out an unannounced inspection of this service on 25 May 2022. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, staffing and good governance.

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. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed 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 The Grange on our website at www.cqc.org.uk.

The Grange accommodates up to 25 people with a learning disability and/or autistic people. People living at the service may also have mental health conditions. People lived across four schemes. These schemes are The Grange, The Courtyard, Priddy Farmhouse and Meadowlands. People have their own apartments with en-suite facilities. Within the services there are some communal areas and The Grange has a separate group kitchen. All of the services are on a working farm site and there are day centre opportunities for people to participate in farm activities. At the time of the inspection there were 25 people living at the service.

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

At this inspection, we found improvements had been made in response to the warning notice we issued previously. The provider had worked with the fire service and commissioned a contractor to undertake required fire safety work.

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 29 July 2022).

Why we inspected

We undertook this targeted inspection to check whether the Warning Notice we previously served in relation to Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met. The overall rating for the service has not changed following this targeted inspection and remains inadequate.

We use targeted inspections to follow up on Warning Notices or to check concerns. They 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.

Follow up

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

Special Measures

The overall rating for this service from our last inspection in May 2022 is 'Inadequate' and the service therefore is 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.

The Grange accommodates up to 25 people with a learning disability and/or autistic people. People living at the service may also have mental health conditions. People lived across four schemes. These schemes are The Grange, The Courtyard, Priddy Farmhouse and Meadowlands. People have their own apartments with en-suite facilities. Within the services there are some communal areas and The Grange has a separate group kitchen. All of the services are on a working farm site and there are day centre opportunities for people to participate in farm activities. At the time of the inspection there were 25 people living at the service.

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

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 statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

Based on our review of the key questions safe, effective, responsive and well-led, the service was not able to demonstrate how they were meeting some of the underpinning principles of Right support, right care, right culture.

Right Support

The service did not always give people care and support in a safe, clean and well-maintained environment.

People were not always able to pursue their chosen interests and achieve their aspirations and goals because of staffing shortages at the service. The home was reliant on agency staff that did not always know people well.

Staff had not always communicated with people in a way that met their needs. Staff had not always supported people in the least restrictive way possible. This had been addressed by the provider. People were supported to have some choice and control of their lives. The policies and systems in the service supported this practice.

People had a choice about their living environment and were able to personalise their rooms.

Staff did everything they could to avoid restraining people. The service recorded when staff restrained people, and staff learned from those incidents and how they might be avoided or reduced. The provider’s behaviour specialist reviewed all incidents to ensure appropriate support was being delivered.

Right Care

Some aspects of people’s medicines were not managed safely.

The service did not always have enough appropriately skilled staff to meet people’s needs and keep them safe.

Health and social care professionals were involved in the care and support of the people living in the home. Referrals had been made to the local community learning disability team.

People received care from staff that had been through a recruitment process. Staff were caring in their approach towards people.

Staff understood how to protect people from poor care and abuse. The service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.

Right Culture

Staff turnover was high. Staffing was not always planned in respect of people’s individual needs which meant they were not always receiving their one to one support. Permanent and regular agency staff knew and understood people well and were responsive to their needs.

There had been a lack of leadership in the home. There had been no registered manager at the service since April 2021.

The provider and the manager had failed to implement a robust system to monitor the quality of the service. Improvement in areas of risk management had not been fully implemented in respect of the property, fire and cleanliness.

The geographic location of the service was isolated. There were limited public buses available to transport people to the local towns and community facilities if they wished. The service had vehicles available at each scheme, however there were not always drivers available.

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 (05 November 2018).

Why we inspected

The inspection was prompted in part due to concerns we received about potential abuse and unsafe staffing levels. A decision was made for us to inspect and examine those risks.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

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

We have found evidence that the provider needs to make improvements. Please see the safe, effective, responsive and well-led sections of this full report.

The overall rating for the service has changed from good to inadequate based on the findings of this inspection. You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for The Grange on our website at www.cqc.org.uk.

Enforcement and Recommendations

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

We have identified breaches in relation to safe care and treatment, safe staffing and good governance at this inspection.

We issued a letter of intent and the provider responded with an action plan to address our most serious concerns.

We made recommendations that the provider reviews their processes to ensure people receive person-centred care and reviews people’s capacity assessments in line with the principles of the Mental Capacity Act 2005.

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

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Special Measures

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.

At the last inspection two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations were found and one breach of the Care Quality Commission (Registration) Regulations. This was because statutory guidance was not being followed when making decisions for people who lacked capacity. Concerns raised at the inspection were not being identified by the provider’s quality assurance systems. Notifications were not being sent in line with statutory guidance. We also made a recommendation to ensure people’s human rights were being protected. Following the inspection, the provider sent us an action plan how they would resolve the concerns and in what time frame. At this inspection we found all areas of concern had been improved.

The Grange 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.

The Grange accommodates up to 25 people with learning disabilities, including autism and mental health issues across four services. These services are The Grange, The Courtyard, Priddy Farmhouse and Meadowlands. Each service is divided into self-contained flats. The services contain between five and seven people. At the time of the inspection there were 24 people living within the services. Some people, especially those living in The Grange, had limited verbal communications. When this was the case, their opinions were captured through observations, interactions they had with staff and their reactions. Each person had their own self-contained flat designed around their likes and needs. Within the services there were some communal areas and the Grange had a separate group kitchen. All the services were on a working farm site and there were day care opportunities for people to participate in farm activities.

The care service was registered prior to the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen”. Registering the Right Support CQC policy. During the inspection we spoke with the management about this guidance.

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. The registered manager oversaw four service managers who were each responsible for running one of the four services.

People were kept safe. Most health and safety checks were completed in line with the provider’s systems. Two areas of improvement were identified during the inspection and immediately resolved by the management. Staff knew how to prevent the spread of infection and people’s medicine was managed safely.

People told us they were happy and others appeared comfortable in the presence of staff. Those able to tell us told us they were kept safe. Risk assessments were carried out to enable people to retain their independence and receive care with minimum risk to themselves or others.

The management had developed positive relationships with people, their families and other professionals. There were enough staff to keep people safe including using regular agency staff to ensure consistency of care. Staff had received a wide range of training to meet people’s needs. Opportunities were in place to ensure staff could undertake specialist health and social care training. Recruitment systems were in place to reduce the risk of inappropriate staff working at the home.

People were protected from potential abuse because staff understood how to recognise signs of abuse and knew who to report it to. When there had been accidents or incidents systems were in place to demonstrate lessons learnt and how improvements were made. People had their healthcare needs met and staff supported them to see other health and social care professionals. When changes were identified to manage health needs staff liaised with health professionals using their excellent links which had been developed.

People were supported to have choice and control over their lives and staff supported them in the least restrictive way possible. There was clear guidance to inform staff how people would give their consent. When people lacked capacity, decisions had been made on their behalf following current legislation. People were supported to eat a healthy, balanced diet and had choices about what they ate. People in three of the services were encouraged to be as independent as possible when preparing their food. For people in the Grange who had less ability to prepare food there were systems were in place to promote choice when people had limited communication to express food preferences.

Care and support was personalised which ensured people could make choices about their day to day lives. Care plans contained information about people’s needs and wishes and staff were aware of them. All staff had excellent knowledge of people, their needs and preferences. Care plans were updated in line with people’s changing needs. People were listened to when they were upset and knew how to complain. There was a system in place to manage complaints.

People told us they liked the staff and we saw there were positive interactions between them. We observed staff were kind and patient. People’s privacy and dignity was respected by staff. Their cultural or religious needs were valued. People, or their representatives, were involved in decisions about the care and support they received.

The service was well led and most shortfalls identified during the inspection had been identified by the management. There was a proactive approach from the management and provider to driving improvements in the home. The provider had completed statutory notifications in line with legislation to inform external agencies of significant events.

The Grange provides accommodation and personal care for up to 25 adults who have a learning ¿disability, autism or mental health needs. The Grange is registered with us as one service but is ¿made up of four separate homes; each has their own identity and caters for a specific group of ¿people who have similar needs or aspirations. The homes are called The Grange, the Courtyard, ¿Priddy Farm House and Meadowlands. The Grange can accommodate six people, the Courtyard ¿seven people, Priddy Farm House five people and Meadowlands seven people. There were 23 ¿people accommodated when we inspected.¿

There were four service managers who were responsible for the day to day running of one ¿designated home; these managers were overseen by the registered manager who was ¿responsible for the service. This is a person who has registered with the Care Quality ¿Commission to manage the service. Like registered providers, they are ‘registered persons’. ¿Registered persons have legal responsibility for meeting the requirements in the Health and ¿Social Care Act 2008 and associated Regulations about how the service is run.¿

People made choices about their own lives, although their legal rights in relation to decision ¿making and restrictions were not always upheld. People knew how to complain; people’s ¿complaints were taken seriously and investigated. ¿

The quality assurance systems in place were not yet fully effective. We had not been notified of ¿each significant event which had occurred at the service in line with the provider’s legal ¿responsibilities.¿

People’s care needs were thoroughly assessed and their move to the service was well planned. ¿One person told us, “I came for a visit and had a look around the farm, my flat and met some staff. ¿I’m happy I moved here. It’s much better than where I lived before.”¿

People were protected from abuse and avoidable harm; risks to people were assessed and well ¿managed. People received effective support with their medicines and to help them manage their ¿behaviour. A range of health and social care professionals were involved in people’s care to ¿ensure their needs were met.¿

People chose a range of activities, work placements and trips out. Staffing levels ensured people ¿could take part in their chosen activities and remained safe.¿

People interacted well with staff and had built trusting relationships with them. Staff were kind, ¿patient and treated people with dignity and respect. One person said, “I get on well with all the ¿staff, they’re good. They’ve really helped me out with things, even difficult things. I’m really happy ¿living here.” ¿

Staff knew people well and understood their care and support needs. Staff supported people to ¿¿'move on' if people chose to. People kept in touch with their friends and relations, were part of ¿their community and were encouraged to be as independent as they could be.¿

People, and those close to them, were involved in planning and reviewing their care and support. ¿Care plans were comprehensive and kept up to date. There were systems in place to share ¿information and seek people's views about their care and the running of the service. ¿

People chose their own meals; they were encouraged to eat a healthy and well balanced diet. ¿One person said, “I do a weekly menu, chose what food I want, do my shopping list, then staff ¿take me shopping.”¿

Staff were well supported and well trained. Communication throughout the service was good; ¿staff felt involved and listened to. One staff member said, “I definitely get enough support. The ¿managers are accessible and they listen.”¿

There was a management structure in the service, which provided clear lines of responsibility and¿

accountability. All staff worked hard to provide the best level of care possible to people. The aims ¿of each individual home were well defined and adopted by staff teams.¿

We have made a recommendation about people’s legal rights in relation to their liberty. ¿

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) ¿Regulations 2014 and one breach of the 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 the report.¿