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Inspection carried out on 18 July 2019

During a routine inspection

About the service

Seacroft Grange Care Village is a residential and nursing care home providing personal and nursing care to 86 people at the time of the inspection. The service can support up to 95 people.

The care home was split into six separate units or ‘communities’ for residential, dementia, nursing and working age adults.

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

People were supported to engage in a wide variety of activities which matched their interest and preferences, and wellbeing staff engaged in innovative projects with local organisations to ensure people’s wellbeing was monitored and improved. There were extensive links with the local community to ensure people were not socially isolated.

People said there were enough staff to meet their needs. Staff recruitment processes were robust, with sufficient background checks.

People received their medicines as prescribed. Staff received training and competency checks before administering medicines. Documentation, ordering and storage arrangements were appropriate.

The environment was clean and well maintained. Staff received training in preventing and controlling infection. The environment was designed to meet people’s needs.

Staff received the proper training and support to meet people’s needs. There was ongoing support through supervisions, one to one’s and spot checks.

People’s physical health and nutritional intake were monitored and recorded by staff. Where appropriate, staff supported people to access external health and social care agencies to ensure they were able to maintain a healthy lifestyle. People’s food choices and needs were taken into account and supported.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People and their relatives said staff were kind, caring and compassionate. People’s diverse needs were taken into account and people were supported to have their needs met.

Staff understood how to protect and promote people’s privacy and dignity. People we spoke with said they were supported to maintain their independence, and have choice over their care.

People, their relatives and staff said the manager was open and supportive. The provider engaged with people, their relatives and staff to gather feedback on how the service was performing and make improvements.

There were a range of quality assurance checks and processes in place to monitor the service’s performance and make improvements. There were action plans where issues were found and they were followed up. There were regular staff meetings to ensure communication was positive and issues were identified and resolved in a timely way.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection (and update)

The last rating for this service was requires improvement (published 20 July 2018).

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.

Why we inspected

This was a planned inspection based on the previous rating.

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.

Inspection carried out on 18 January 2018

During a routine inspection

This was an unannounced inspection, which took place on 18, 23 and 24 January 2018. At the last inspection in June 2016, we found two breaches of the legal requirements relating to the safe management of medicines and governance arrangements. At the last inspection we issued warning notices in respect of these breaches. At this inspection we found the provider had undertaken work to address previous issues identified with medicines management. Whilst a number of previous concerns in this area had been addressed and we saw improvements had been made, we found ongoing concerns with the safe management of medicines and governance.

Seacroft Grange Care Village is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

Seacroft Grange Care Village provides residential, rehabilitation and nursing care for up to 95 people. The accommodation is set over three floors across two buildings, with a central facility which contains a coffee shop, spa, hair salon, therapy room and cinema. It is situated in a residential area of Leeds with good access to local facilities and access to transport links.

There was a registered manager in post 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 2008 and associated Regulations about how the service is run.

Although there had been some improvement in the management of medicines since our last inspection, there were still shortfalls in administration and recording.

There had been some improvements in the governance and quality monitoring structures at the service since the previous inspection. However, further review of quality assurance systems and governance in the service is needed to ensure improvements continue to be made especially in relation to medicine management.

People and relatives told us they felt safe and secure. Risks to people were assessed and managed appropriately.

There were enough staff to provide care safely. The registered manager monitored the number of staff required through the use of a dependency tool. Safe recruitment systems were in place to make sure staff were suitable to work with vulnerable people.

Staff were given sufficient training and support to carry out their roles effectively. Staff had access to extra training and were supported to pursue their career goals in a constructive way.

Staff demonstrated a good understanding of the Mental Capacity Act (MCA) 2005 and ensured important decisions were made within the best interest decision making process. Deprivation of Liberty Safeguards (DoLS) applications were made appropriately and staff demonstrated an understanding of this and why they were in place to protect vulnerable adults.

People’s health and wellbeing was supported by knowledgeable staff who were proactive in monitoring people’s health and making referrals to health professionals where necessary.

People told us they were cared for by kind and compassionate staff who supported their independence, respected their individuality and protected their privacy and dignity.

There was a wide range of activities and entertainment on offer, which took into account people’s like, dislikes and personal preferences. The service had established good links with the local community and used these to the benefit of people living at the service.

There was a complaints process in place, and people told us they knew how to make a complaint. Complaints were responded to in a timely way.

There was good engagement with people through questionnaires and surveys, and evidence that people’s feedback was listened to. The

Inspection carried out on 20 June 2017

During a routine inspection

This was an unannounced inspection carried out on 20 and 22 June 2017. At the last inspection in March 2016 we found four breaches of the legal requirements relating to the safe management of medicines, staff supervision, staff training and understanding of the Mental Capacity Act 2005 and insufficient controls in place to ensure potential evidence of abuse was properly investigated and reported as required. At this inspection we found on-going concerns with the safe management of medicines and that governance arrangements were not robust enough.

Seacroft Grange Care Village is a purpose built facility which provides residential, rehabilitation and nursing care for up to 95 people. The accommodation is set over three floors across two buildings, with a central facility which contains a coffee shop, spa, hair salon, therapy room and cinema. It is situated in a residential area of Leeds with good access to local facilities.

The manager had been in post nine days on the first day of our inspection. They were not registered with the Care Quality Commission but said they intended to submit an application for registration. 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 and associated Regulations about how the service is run.

Medicines were not managed safely. We found there were continuing shortfalls in managing medicines. The shortfalls included those identified at previous inspections and some new concerns which placed people’s health at risk of harm.

People who used the service, their relatives and staff told us the service had improved since the new management team were in place. Staff said they found the managers supportive and approachable. We saw information was gathered which included; incidents, falls and complaints but the provider did not have fully effective systems in place to identify trends, patterns or how they could learn lessons and prevent repeat events. A range of checks and audits were undertaken to ensure people's care and the environment of the home were safe and effective. However, these checks had failed to identify the issues we noted around the management of medicines.

People and relatives we spoke with told us they felt the service was safe. Risks to people using the service were assessed and plans put in place to minimise and manage any identified risks. Overall we found there were enough staff to make sure people received appropriate care and support. We have made a recommendation that the provider keeps staffing levels under review to ensure there are sufficient staff to meet people’s needs.

Safe recruitment systems were in place to ensure staff were suitable to work in a care setting with vulnerable people. Staff knew how to keep people safe from the risk of harm and abuse; they had received relevant safeguarding training and knew how to report issues of concern. There were effective procedures in place to make sure any concerns about the safety of people who used the service were appropriately reported.

We found people's health care needs were met and relevant referrals to health professionals were made when needed. People's nutrition and hydration needs were met. Nutritional risk was assessed and people’s weight was monitored. There was a choice of food and drink available to suit people’s individual needs.

When people were assessed as lacking capacity, staff acted within the principles of the Mental Capacity Act (MCA) 2005 and ensured important decisions were made within best interest decision making processes. We saw appropriate Deprivation of Liberty Safeguards (DoLS) authorisations or applications had been made for people the service had identified were or likely to have their liberty deprived.

Staff had completed training to ensure the care and support

Inspection carried out on 30 March 2016

During a routine inspection

Our inspection took place on 30 March 2016 and was unannounced. At our last full inspection carried out on 15 December 2014, 5 January 2015 and 3 March 2015 we found the provider was in breach of Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activity) Regulations 2014. People’s care plans did not always contain enough information to ensure people received safe, effective care. We returned in July 2015 to look at whether the provider had taken action to improve in this area. We concluded they had not and issued a warning notice. At this inspection we found the provider had followed their action plan and were meeting the legal requirements in this area.

Seacroft Grange Care Village is a purpose built facility which provides residential, rehabilitation and nursing care for up to 95 people. The accommodation is set over three floors across two buildings, with a central facility which contains a coffee shop, spa, hair salon, therapy room and cinema. It is situated in a residential area of Leeds with good access to local facilities.

The manager of the day of our inspection had been in post for five weeks. They were not registered with the Care Quality Commission but had submitted an application for registration. 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.

We found information about accidents and incidents in the home had not always been reported appropriately. The manager told us they had already identified the reporting systems did not work. We asked the manager to undertake a review of reports, and they updated us with their findings after the inspection.

We looked at the management of people’s medicines. The provider had systems and processes in place to manage people’s medicines, and though these were safe overall we did identify some inconsistencies which we brought to the attention of the manager on the day of the inspection.

Some people who used the service and some staff told us there were not always enough staff to meet people’s support and care needs, though other people told us there were. We did not observe people being kept waiting for assistance on the day of the inspection.

Care plans contained risk assessments where these were needed to help keep people safe, and we saw these were kept up to date.

The provider carried out a range of checks to ensure that recruitment was safe.

We found staff had not been supported with regular supervision meetings for an extended period of time. The operations director confirmed this, and showed us they had put a programme in place to ensure supervisions were carried out in future.

Care plans contained details of a range of consents including consent to treatment, medication and photography. We observed staff asking people before providing assistance. We found few staff had received training in the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

We saw improvement in the dining experience. People told us they enjoyed the food served in the home, and we saw evidence people were asked for their opinions about the menus on a regular basis.

People and their relatives told us staff were caring, and gave a variety of positive feedback about their experiences. We observed staff were attentive to people and spoke to them with kindness.

We found the quality of information in people’s care plans had improved, and staff told us they found them easier to understand. We saw evidence care plan reviews had been carried out and people and their relatives could tell us how they had been involved in the writing or review of care plans.

We looked at the management of complaints and found there was information about how to raise concerns availabl

Inspection carried out on 29 July 2015

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

We carried out an unannounced comprehensive inspection of this service on 15 December 2014, 05 January and 03 March 2015. Breaches of legal requirements were found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We undertook this unannounced focused inspection on 29 July 2015 to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Seacroft Grange Care Village Home on our website at www.cqc.org.uk

Seacroft Grange Care Village is a purpose built facility which provides residential, rehabilitation and nursing care for up to 95 people. The accommodation is set over three floors across two linked buildings.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

At our last inspection carried out on 15 December 2014, 5 January 2015 and 3 March 2015, we saw that peoples’ care plans were not accurate or complete and concluded that the provider was in breach of Regulation 17 HSCA 2008 (Regulated Activities) Regulations 2014 ‘Good governance’. We asked them to provide an action plan showing us how they would become compliant with this regulation and by when. The provider told us that they would be compliant by 20 April 2015. We returned to inspect the changes that they had made on 20 July 2015. We found a care plan audit had been carried out but no changes to care plans had been made. Some care plans were still incomplete or inaccurate, meaning that people were at risk of receiving inappropriate safe care. We did not see a robust plan in place which showed who would update care plans and by when. You can see what actions we told the provider to take at the back of the full version of the report.

Inspection carried out on 15 December 2014, 5 January 2015 and 3 March 2015

During a routine inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, and to provide a rating for the service under the Care Act 2014.

This was an unannounced inspection carried out on 15 December 2014, 5 January 2015 and 3 March 2015. At the last inspection in August 2014 we found two breaches of legal requirements which included care and welfare of people who use services and medicines. We issued warning notices and told the provider to be compliant with the warning notices by the 13 November 2014. At this inspection we found there was a remaining medicines breach, however we asked a pharmacy inspector to visit at a later date and we found improvements had been made. We also found improvements had been made with regard to care and welfare.

Seacroft Grange Care Village is a purpose built facility which provides residential, rehabilitation and nursing care for up to 95 people. At the time of our inspection there were 67 people living there. The home did not have a registered manager in place, however the new manager has now become the registered manager. 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.

At this inspection we found that not all the improvements required for the administration of medicines had been completed. We found some peoples medication was not being given as prescribed. We saw the storage of some medication was not as directed by the manufacturer. However, during the March 2015 inspection we found this had improved.

On our arrival at Seacroft Grange Care Village we found the premises were unsecured and there were no members of staff around. This meant we were able to move around some parts of the home unchallenged. This puts the safety of people who use the service at risk.

We found there were sufficient staff to keep people safe. We saw staff were attentive and people did not have to wait long for assistance. Staff were kind to people and it was clear from the interactions we witnessed staff knew people well. We did however, see one instance during the lunch time meal of a person not being treated with dignity.

Staff had a good understanding of safeguarding and people who used the service told us they felt safe living there. We reviewed peoples care files and found most had up to date risk assessments in place.

We found not every person had mental capacity act assessments in their care plans, in some cases these would be required to ensure people were being supported to make decisions where they could. We found not everyone had signed consent documents in their care plans.

Staff training was up to date and where people required training in specialist areas of care we found the provider was sourcing this type of training. Staff had a comprehensive induction which gave them a good insight into what was required of them.

Some care plans we looked at contained good detailed information on how to care for people and in others we found important information was missing. Some documents were blank and others had not been reviewed in the timescales stated by the provider.

People who used the service were asked for their opinions about the service and where possible these were acted upon

People who used the service and staff told us they thought the new manager had made some good changes and they thought the service had improved.

During this inspection we found a different breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 which has since been replaced by the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 . You can see what action we told the provider to take at the back of the full version of this report.

Inspection carried out on 14, 15 August 2014

During an inspection in response to concerns

This inspection was conducted by two inspectors as a result of concerns raised. During our inspection we considered our five key questions: Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

Below is a summary of what we found. The summary is based on information received prior to our inspection, our observations during the inspection, speaking with people who used the service, their relatives, and the staff supporting them as well as from looking at records.

Is the service safe?

We observed a member of care staff approach a person with medication which they refused to take. This was then given to the nurse on duty. We spoke with the member of staff who told us the medication had been left on the dining room table; they therefore had attempted to give it to the person. We were told there were several occasions where people's medication was left with the person by staff and not taken.

We saw a person was prescribed morphine to be taken 12 hours apart. We found over a period of six days the morphine had been administered less than 12 hours apart on four occasions.

We were told a person had been brought to the home by paramedics during the previous evening. The home were not expecting anyone to be admitted, however this person was admitted and had been 'put to bed and given some supper'. It later emerged the person should have been taken to another care home nearby.

Is the service effective?

We looked at systems in place for people who required 'end of life' care and found on two occasions this had not been effectively managed. We saw 'end of life' care plans were not always followed.

We looked at how Seacroft Grange Care Village was meeting people's nutritional needs. This was because we were told people who lived at Seacroft Grange Care Village were not given enough to eat and the food budget had been cut. Over the two days of our inspection we observed all three meals. People had a good choice at breakfast time; there was a cooked option which included sausage, bacon, hash browns and black pudding. Staff told us if people wanted eggs or beans they would be cooked in the small kitchen on the unit. We saw there was a choice of cereals including porridge which could be fortified for people, yoghurts and juice in the fridge on each unit.

We spoke with kitchen staff who told us there had been no reduction in the food budget for the home; we were shown the fridges, freezers and store cupboards and found they were well stocked.

We spoke with people who lived at Seacroft Grange Care Village and some of their relatives, their comments included;

“They give second helpings with the food. I couldn’t be happier.”

"The food is lovely, we get more than enough."

Is the service caring?

During our inspection of Seacroft Grange Care Village we saw some good interactions between people who used the service and care staff. We spoke with some relatives of people who used the service and their comments included;

"Nothing but praise."

"He is well looked after, always well turned out and clean shaven."

"I don't think they neglect anyone."

Is the service responsive?

We looked at the care plans of four people who used the service and in one care plan we saw instructions on how the person should be assisted to mobilise. It stated the person 'was able to stand and take a few steps using their zimmer frame with the assistance from two care staff'. Throughout the day we observed the person being assisted by only one person.

During the day we observed staff assisting people and generally staff were able to meet people's needs without too much delay. However, during the lunchtime meal on one of the units we saw two members of care staff were serving people their food in the dining room and a third member of staff who was serving people their food in their bedroom. During that time we heard call bells which were taking some considerable time to answer as the third member of staff was also responding to the call bells. We observed members of nursing staff ignoring the call bells and continuing with their paperwork which put the care staff under unnecessary pressure.

Is the service well led?

Staff we spoke with told us, "They do rota changes without asking. Dementia is not my field, I am used to nursing.", “We don’t see the manager very often.” and “We move about when short – this is frequent on Fairview.”

Inspection carried out on 20 May 2014

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

Our inspection team was made up of two inspectors, a pharmacy inspector and a nurse specialist advisor. They helped answer our five questions: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people who used the service, the staff supporting them and from looking at records.

Is the service safe?

People were treated with respect and dignity by staff.

We observed staff were wearing appropriate personal protective equipment (P.P.E), which included gloves and aprons; staff were seen to be using alcohol hand gel. There was a comprehensive and up-to-date control of infection policy and procedure in place. An infection control audit had been carried out in April 2014.

Most people who used this service had their medicines given to them by staff. We watched a member of staff giving people their medicines. They followed safe practices and treated people respectfully.

Seacroft Grange Care Village had policies and procedures in relation to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). The provider was in the process of completing applications where DoLS authorisations were required.

People were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not maintained. Records relating to medication were not completed correctly placing people at risk of medication errors.

We looked at three staff files and found evidence that showed the service took all necessary precautions to ensure they only employed staff that were of good character, had the skills and qualifications necessary to effectively care for older people and were physically and mentally fit for that work.

Is the service effective?

People's health and care needs were assessed. Specialist dietary, mobility and equipment needs had been identified in care plans where required.

Is the service caring?

People were very positive about the care at Seacroft Grange Care Village. One person who used the service said, "I am very comfortable here, the staff are lovely." A relative of person who used the service said, “It’s brilliant here; (name of person) is really happy and really settled.” Another said, "Superb place."

Is the service responsive?

We observed people being assisted to take part in activities in the bistro area of the home. We found staff interactions with people who used the service to be polite, caring and supportive of their needs.

We asked for and received a log of complaints. We found each of these had been responded to within a reasonable timescale and where possible had been dealt with to the satisfaction of the complainant.

Is the service well led?

We saw there had been a staff meeting for nursing staff where items such as nutrition and who was to lead the medication audits was discussed. We were told there had not been any other staff meetings.

We looked at various audits the provider had completed since our last inspection and found there had been for example; room audits, care plan audits and a care home validation audit. Where necessary action plans had been instigated.

Inspection carried out on 19 February 2014

During an inspection in response to concerns

We observed during lunch, we saw staff understood people’s likes, dislikes and appetites. People were given a choice of meal along with a cold drink. Staff were very polite and respectful.

We looked at compliments received by the service, one person had said, “I would just like to say a big thank you to you all for your kindness, care and patience in helping my relative (person’s name) to settle in at Seacroft. “ Another said, “The staff are all so kind.” Staff we spoke with were very positive about the care at Seacroft Grange Care Village, one member of staff told us, “Care is 100%. Full on care”

We looked at people’s care plan’s and found them difficult to navigate around. We found the templates in place if completed appropriately would provide good information. We found there was a lack of information in people’s care plans for example in one care plan we looked at it stated a person should have attended a hospital appointment but we were unable to see if this had happened.

We looked at all occupied areas of the home and found there was a general lack of cleanliness and infection control measures being taken in most areas, with malodours in some areas.

There was a locked medication room on each floor. Most medication rooms contained a refrigerator, a medication trolley, medicine cupboards and a Controlled Drugs cupboard.

We looked at the medication administration records (MAR) for three people who used the service. We saw one person had been prescribed a drug in December 2013. The dose indicated on the bottle had been incorrectly transcribed to the MAR sheet; therefore the person had received half the recommended dose over a long period of time.

The provider had not carried out any checks or audits to ensure the service was being delivered safely. We saw the provider had several policies which once implemented should give the provider a good overview of the standard of care being delivered.