Graywood Care Home

At the last inspection on 29th August 2017, we found a continued breach of Regulation 17. The registered person had failed to identify shortfalls at the service through regular effective auditing. In addition, records were not all accurate and up to date. We asked the provider to take action to make improvements and these actions had been completed.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key question of well-led to at least good. At this inspection we found that the provider and manager had introduced a series of checks and audits that had ensured that shortfalls were quickly identified and resolved. We also found that records such as care plans and risk assessments contained more detail and were regularly updated in line with people's changing needs. As a result, Graywood is no longer in breach of Regulation 17.

Graywood accommodated 9 people with mental health difficulties. People's ages varied from 30 to 80 years and they all lived in one adapted building. Graywood is a ‘care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The care home was registered to one person who is the provider and therefore the Graywood does not require a registered manager. The provider was the registered person. Registered persons have the 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 provider had overall responsibility for the Graywood.

The atmosphere at Graywood was calm and relaxed. People had a high level of independence and mobility and came and went as they pleased. There was a kind and supportive culture which was embraced by all. People smiled and laughed and it was clear that everyone cared for each other. Staff knew people very well and spoke about them with fondness. One person told us; " I do like it here. Everything is so good, the staff are so good, the manager is good, they are all so helpful".

People told us that they felt safe. Staff had appropriate training to protect people from harm and abuse and any risks to people were identified and mitigated. The manager had an open-door policy and people and staff told us that they would talk to the manager straight away if they had any concerns. People were encouraged to take positive risks by trying new activities and opportunities, which promoted exercise, wellbeing and independence.

The small, longstanding team of staff knew people well and had regular training to keep up-to-date with developments in the law and best practice. They were supported by the manager and staff felt that any concerns they raised to the manager would be investigated appropriately. Checks were carried out to ensure any new members of staff were safe to work with people.

Medicines were stored and given to people safely. Guidance was in place to ensure that staff knew what medicine people took and the actions that should be taken in case of a medical emergencies such as; when people became unwell. Regular checks took place to ensure mistakes were identified and resolved.

The premises were clean, smelt fresh and met people's needs. Staff knew how to protect people from infection. Peoples rooms were decorated to their own personal taste and people helped with the cleaning of the property. Maintenance issues were quickly identified and resolved.

Graywood provided people with person-centred care and support. The manager received best practice guidance from accredited organisations and attended local forums. This information was passed to staff through meetings and supervisions. As a result, people were involved in all decisions relating to their care and support, and people told us that their decisions and choices were respected. Care plans were thorough, person-centred and updated regularly to reflect people's changing needs.

People were encouraged to live healthy, independent lives. Staff encouraged people to exercise and eat healthily. Some people attended a local gym. People decided upon a menu and alternative choices were always available.

When people were unwell, staff responded quickly and contacted the relevant professionals. Policies and procedures were in place to ensure that care was responsive and delivered consistently with Graywood and throughout health care services.

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. A person told us; "If I make a decision they respect it".

The manager sought feedback from staff and people using the service and an accessible complaints procedure was available. Regular checks were introduced to ensure mistakes were identified and resolved. Complaints, compliments, feedback, errors and incidents were recorded and these were collected and analysed by the manager to identify if lessons could be learnt. We discussed how the managers audits and analysis could be recorded for clarity and the manager said they would take action before the next inspection.

People were asked about their end of life preferences and their personal information was kept securely. Staff respected people's privacy, dignity and confidentiality.

There were 12 people living at the service at the time of the inspection. The care and support needs of the people were varied. There was a wide age range of people with diverse needs and abilities. The youngest person was in their 30’s and the oldest was over 80 years old. As well as needing support with their mental health, some people required care and support related to their physical health. People were able to make their own decisions about how they lived their lives. They were able to let staff know what they wanted and were able to go out independently.

There was no registered manager in post. This was because the service was registered to one person who is the provider and therefore the service does not require a registered manager. The provider was the registered person. 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 provider had overall responsibility for this service. The provider spent time at the service and there was an assistant manager in post who gave support with the day to day running of the service. The service was a family run business and family members were employed by the provider. The provider, assistant manager and staff supported us throughout the inspection.

At the last inspection in September 2016 we found a breach of regulations and the service was rated ‘Requires improvement’ . We issued a requirement notice relating to a lack of good governance. We asked the provider to take action and the provider sent us an action plan. The provider wrote to us to say what they would do to meet legal requirements in relation to the breaches. We undertook this inspection to check that they had followed their plan and to confirm that they now met legal requirements. Improvements had been made but further improvements were required.

Staff and people told us that the service was well led and that the management team were supportive and approachable. They said there was a culture of openness within Graywood Care Home which allowed them to suggest new ideas which were often acted on. The assistant manager had sought feedback from people, staff and others involved with the service. Their opinions had been captured, and analysed to promote and drive improvements within the service. Informal feedback from people, their relatives and healthcare professionals was encouraged and acted on whenever possible.

The assistant manager undertook checks of the environment to make sure everything was safe. Audits and health and safety checks were regularly carried out by the assistant manager and these were recorded. However, the assistant manager had not identified the shortfalls in recording some information. Some records had not been completed and did not contain all the information needed to support people.

On the whole, there was guidance in place for staff on how to care for people effectively and safely. Risk assessments were designed to keep most risks to minimum without restricting people’s activities or their life styles and promoting their independence, privacy and dignity. However, on occasions potential risks to people were identified and discussed but guidance on how to safely manage the risks was not always available and some risk assessments were not accurately recorded. This is an area for improvement.

At the last inspection fire safety checks which were supposed to be done weekly had not been completed. At this inspection all safety checks had been completed at the required intervals Emergency plans were in place so if an emergency happened, like a fire, the staff knew what to do. There were regular fire drills at the service so that people knew how to leave the building safely. People's personal evacuation emergency plans (PEEPS) had been reviewed and updated to explain what individual support people needed to leave the building safely. There was no ‘grab- bag’ available at the service. A ‘grab bag’ is a bag that contains important information about people like what medicines they take that can be taken out of the building quickly in the event of an emergency. The assistant manager said they would implement this.

Before people decided to move into the service their support needs were assessed by the assistant manager to make sure they would be able to offer them the care that they needed. The findings of the assessments had not been recorded so that they could be used to develop a care plan. The care and support needs of each person were different and each person had a care plan which was personal to them. Care plans recorded the information needed to make sure staff had guidance and information to care and support people in the way they preferred. People were able to come and go as they pleased and organise their own daily activities. People would benefit from more direction and support from staff when planning and undertaking activities

People had an allocated keyworker. A key worker was a member of staff who takes a key role in co-ordinating a person's care and support and promotes continuity. Throughout the inspection people were treated with kindness and respect. Staff were attentive and the atmosphere in the service was calm, and people were comfortable in their surroundings. Contact with people's family and friends who were important to them was supported by staff.

People's medicines were handled and managed safely. People's physical and mental health was

monitored and people had regular contact with specialist health care services. If people were unwell or their health was deteriorating the staff contacted their doctors or specialist services.

People said that they enjoyed the food and it was always of a good standard. They said there was plenty of choice and the portions at meal times were good. They told us they had involvement in the menu to ensure they had their favourite foods.

People were settled, happy and contented. Staff were caring and respected people's privacy and dignity. There were positive and caring interactions between the staff and people were comfortable and at ease with the staff. Everyone told us their privacy was respected and they were able to make choices about their day to day lives.

The staff knew people well and were familiar with their lifestyle wishes and preferences. This continuity of care and support resulted in building people's confidence to enable them to make more choices and decisions themselves. People's individual religious preferences were respected.

Staff understood how to protect people from the risk of abuse. Staff had received training on how to keep people safe. They were aware of how to recognise and report safeguarding concerns both within the service and outside agencies such as the local authority safeguarding team. Staff were confident to whistle-blow to the registered manager if they had any concerns, and were confident that appropriate action would then be taken.

The assistant manager and staff understood how the Mental Capacity Act (MCA) 2005 was applied to ensure decisions made for people without capacity were only made in their best interests. CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care services. These safeguards protect the rights of people using services by ensuring that if there are any restrictions to their freedom and liberty, these have to be agreed by the local authority as being required to protect the person from harm. At the time of the inspection no-one living at the service was subject to a DoLS restriction. Although the assistant manager had considered peoples mental capacity to make the decisions, this had not been recorded.

There was a stable staff team who had worked at the service for many years. There were sufficient numbers of staff to meet people’s needs. The assistant manager was in the process of recruiting new staff. There were staff recruitment procedures to ensure staff were suitable for their job roles. Staff had the knowledge and skills to meet people’s needs, and attended regular training courses. There was a training programme, including induction training in place to ensure that all staff received the basic and specialist training they needed to ensure they had the skills and competencies to care and support the people. Staff received regular one to one meetings with the assistant manager and an annual appraisal to discuss their training and development needs. Staff were supported by the assistant manager and felt able to raise any concerns they had or suggestions to improve the service.

The complaints procedure was available and accessible. People knew how to complain and felt confident their complaints would be listened to and acted on. People had opportunities to provide feedback about the service provided both informally and formally. The assistant manager was aware they had to submit notifications to CQC in an appropriate and timely manner in line with CQC guidelines.

We found a breach of regulation 17 the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was a continuous breach of this regulation which was also identified at the two previous inspections. You can see what action we told the provider to take at the back of the full version of this report.

There were 12 people living at the service at the time of the inspection. The care and support needs of the people were varied. There was a wide age range of people living at the service with diverse needs and abilities. The youngest person was in their 40’s and the oldest was over 90 years old. As well as needing support with their mental health, some people required care and support related to their physical health. People were able to make their own decisions about how they lived their lives. They were able to let staff know what they wanted and were able to go out independently.

There was no registered manager in post. This was because the service was registered to one person who is the provider and therefore the service does not require a registered manager. The provider was the registered person. 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 provider had overall responsibility for this service. The provider spent time at the service and there was an assistant manager in post who gave support with the day to day running of the service. On the day of the inspection the provider was not available. The service was a family run business and family members were employed by the provider. The assistant manager and staff supported us throughout the inspection.

At the last inspection in February 2016 we found breaches of regulations. We issued requirement notices relating to safeguarding people from abuse, safe care and treatment, fit and proper persons employed, staff training and staff deployment, person centred care and good governance. We asked the provider to take action and the provider sent us an action plan. The provider wrote to us to say what they would do to meet legal requirements in relation to the breaches. We undertook this inspection to check that they had followed their plan and to confirm that they now met legal requirements. There were seven breaches identified at the previous inspection and at the time of this inspection the provider had complied with six breaches and parts of the other breach. The provider had not fully met their legal requirements but improvements had been made.

A system to recruit new staff was in place. This made sure that the staff employed to support people were fit to do so. At the last inspection recruitment processes were not fully adhered to. At this inspection improvements had been made but there was an area that needed further improvement.

At the last inspection not all risks to people had been kept to a minimum. At this inspection improvements had been made but there were still some shortfalls. Fire safety checks which were supposed to be done weekly had not been completed since May 2016. Emergency plans were in place so if an emergency happened, like a fire, the staff knew what to do. There were regular fire drills at the service so that people knew how to leave the building safely. People’s personal evacuation emergency plans (PEEPS) had not been reviewed and updated to explain what individual support people needed to leave the building safely. After the inspection the assistant manager sent information to evidence this was being addressed. We have made a recommendation about the fire safety within the service.

Individual risks to people's safety were assessed and managed appropriately. Risk assessments identified people's specific needs, and showed how risks could be minimised. When new risks had been identified the assistant manager had taken action to prevent them from re-occurring. Keyworkers updated risk assessments and passed the information to the rest of the staff so that people would be safe.

At the previous inspection the management had not identified and taken action to make sure the all the systems used at the service were checked and audited regularly and that shortfalls were identified and improvements made. They had not asked stakeholders for their opinion of the service to identify shortfalls and make improvements. At this inspection improvements had been made and regular audits were undertaken on most systems used at the service, however the management had failed to identify the fire safety checks had not been completed for four months and had not asked stakeholders for their opinion of the service so that their suggestions could be acted on to improve the service.

At the last inspection procedures to protect people from abuse were not adhered to. At this inspection improvements had been made. No incidents had occurred that required reporting to the local safeguarding team but the management team and staff were aware of the type of events that did need reporting. Staff had received up to date safeguarding training and were able to explain what action they would take if abuse was suspected or had occurred. People told us they felt safe at the service; and if they had any concerns, they were confident these would be addressed quickly by the provider or the assistant manager. Staff were confident to whistle-blow to the provider or assistant manager if they had any concerns and were confident appropriate action would be taken. The assistant manager responded appropriately when concerns or complaints were raised. The assistant manager was aware of when they had had to notify the Care Quality Commission (CQC) of events or incidents that occurred at the service.

At the last inspection staff were not deployed effectively to meet people’s individual needs. At this inspection improvements had been made and staff had more time to spend with people to encourage, support, motivate and involve people to do daily activities. People benefitted from individual support and input.

At the last inspection staff had not received all the continuous training and updates they needed to carry out their roles effectively and safely. At this inspection improvements had been made and staff had the skills and training they needed to support people. Staff had completed induction training when they first started to work at the service. Staff had received regular supervisions (one to one meetings with a senior member of staff) and there were regular staff meetings. Annual appraisals had been booked for staff in the next few months. Staff said they were supported by the management.

The assistant manager and staff understood how the Mental Capacity Act (MCA) 2005 was applied to ensure decisions made for people without capacity were only made in their best interests. CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care services. These safeguards protect the rights of people using services by ensuring that if there are any restrictions to their freedom and liberty, these have to be agreed by the local authority as being required to protect the person from harm. At the time of the inspection no-one living at the service was subject to a DoLS restriction and everyone had been assessed as having full mental capacity to make the decisions they wanted to about how they lived their lives.

Before people decided to move into the service their support needs were assessed by the provider and assistant manager to make sure they would be able to offer them the care that they needed. The care and support needs of each person were different and each person’s care plan was personal to them. People had been involved in writing the information in their care plans. There was the information needed to make sure staff had guidance to care and support people in the safest way. People said they were satisfied with the care and support they received.

People's medicines were handled and managed safely. At the last inspection some medicine records were not completed accurately and there was a lack of detailed guidance for medicine needed on a 'when needed' basis. At this inspection improvements had been made. People’s physical and mental health was monitored and they had regular contact with specialist health care services. If people were unwell or their health was deteriorating the staff contacted their doctors or specialist services.

People said that they enjoyed their meals. People were offered and received a balanced and healthy diet. People were encouraged to have a diet that specifically met their needs. They had a choice about what food and drinks they wanted. If people were not eating enough they were seen by dieticians or their doctor and a specialist diet was provided.

People were settled, happy and contented. Staff were caring and respected people’s privacy and dignity. There were positive and caring interactions between the staff and people were comfortable and at ease with the staff. Everyone told us their privacy was respected and they were able to make choices about their day to day lives.

People told us they received care that was individual to them. They felt staff understood their specific needs. Staff had built up relationships with people and were familiar with their life stories, wishes and preferences. This continuity of support had resulted in the building of people’s confidence to enable them to make more choices and decisions themselves and become more independent. People were involved in activities which they enjoyed. People talked about social events they had taken part in or were planning.

Staff and people told us that the ser

There were 13 people living at the service at the time of the inspection. The care and support needs of the people were varied. There was a wide age range of people living at the service with diverse needs and abilities. The youngest person was in their 40’s and the oldest was over 90 years old. As well as needing support with their mental health, some people required care and support related to their physical health. People were able to make their own decisions about how they lived their lives. They were able to let staff know what they wanted and were able to go out independently.

There was no registered manager in post. This was because the service was registered to one person who is the provider and therefore the service does not require a registered manager. The provider was the registered person. 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 provider had overall responsibility for this service. The provider was at the service every day and there was a deputy manager in post who gave support with the day to day running of the service. The service was a family run business and family members were employed by the provider. The deputy manager, staff and the provider supported us throughout the inspection.

The management and some staff knew how the Mental Capacity Act (MCA) 2005 was applied to ensure decisions made for people without capacity were only made in their best interests. CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLs) which applies to care services. These safeguards protect the rights of people using services by ensuring that if there are any restrictions to their freedom and liberty, these have been agreed by the local authority as being required to protect the person from harm. At the time of the inspection no-one living at the service was subject to a DoLs restriction and everyone had full mental capacity to make the decisions they wanted to about how they lived their lives.

Before people decided to move into the service their support needs were assessed by the provider and deputy manager to make sure they would be able to offer them the care that they needed. The care and support needs of each person were different and each person’s care plan was personal to them. People had been involved in writing the information in their care plans. In some care plans, but not in all, there was the information needed to make sure staff had guidance to care and support people in the safest way. People indicated they were satisfied with the care and support they received. When people’s needs changed some care plans had not been reviewed and updated to reflect the changes. Other plans had been updated. Potential risks to people were identified but full guidance on how to safely manage the risks was not always available. This left people at risk of not receiving the interventions they needed to keep them as safe as possible. People had an allocated keyworker who was involved in their care and support. A key worker was a member of staff who takes a key role in co-ordinating a person’s care and support and promoted continuity.

People's medicines were not always handled and managed as safely as they could be. Some medicine records were not completed accurately. There was a lack of detailed guidance for medicine needed on a 'when needed' basis. People’s physical and mental health was monitored and they had regular contact with specialist health care services. If people were unwell or their health was deteriorating the staff contacted their doctors or specialist services.

People said that they enjoyed their meals. People were offered and received a balanced and healthy diet. They had a choice about what food and drinks they wanted. If people were not eating enough they were seen by dieticians or their doctor and a specialist diet was provided.

Safeguarding procedures were in place to keep people safe from harm. On two occasions these procedures had not been followed by the provider. Management had not consulted with the local authority safeguarding team when incidents had occurred which they should have done as part of those procedures. People told us and indicated that they felt safe at the service; and if they had any concerns, they were confident these would be addressed quickly by the provider or the deputy manager. The staff had received training to recognise and report safeguarding concerns but this had not been updated since 2013 and staff were unsure about some aspects of protecting people and what constituted abuse. There was no available copy of the local authority’s ‘Adult Protection Policy Protocols and Guidance available for staff to refer to if they needed to. Staff were confident to whistle-blow to the provider or deputy manager if they had any concerns and were confident appropriate action would be taken.

On the whole staff were caring and respected people’s privacy and dignity. There were positive and caring interactions between the staff and people were comfortable and at ease with the staff. On one occasion we observed that staff could have been more engaging and respectful when people were being given their medicines. Everyone told us their privacy was respected and they were able to make choices about their day to day lives.

There was a stable staff team working at the service, most had been there for many years. They knew people well and how they liked things done. There were enough staff available for people’s care and support needs but staff had many tasks to complete throughout their shifts especially the morning shift. They had to clean, prepare meals, serve meals, and give people their medicines. They were so busy they had very little time to spend with people to support, encourage, organise and motivate people to do things during the day. People were left to their own devices about what they did and where they spent their time. This suited some people but other people would have benefitted from individual support and input from staff.

Staff had completed induction training when they first started to work at the service but all staff had not received all the continuous training and updates they needed to carry out their roles effectively and safely. Staff had received regular supervisions (one to one meetings with a senior member of staff) and there were regular staff meetings. Staff said that they supported by the management.

Staff were not always recruited safely. The provider had policies and procedures in place for when new staff were recruited, but these were not always followed. All the relevant safety checks had not been completed before staff started work. Some application forms did not show a full employment history and gaps in employment had not been explored when staff were interviewed. Some staff did not have two references on their files and some of the references did not identify the person who had written the reference.

There was a complaints procedure but the complaints procedure was not easily available or accessible to people or others who visited the service. People told they knew who they would complain to within the service and felt they would be listened to but they had no information available to direct them to complain to anyone outside the service.

There were some quality assurance systems in place. Emergency plans were in place so if an emergency happened, like a fire the staff knew what to do. Checks were done to ensure the premises were safe, such as fire and health and safety checks. The checks for the fire alarms were done weekly and other fire checks were completed monthly. There were regular fire drills at the service so that people knew how to leave the building safely. Other health and safety checks were regularly carried out but some checks and audits had not been done. The management had not identified and taken action to make sure the all the systems used at the service were checked regularly and that shortfalls were identified and improvements made.

Staff and people told us that the service was well led and that the management team were supportive and approachable. They said there was a culture of openness within Graywood Care Home which allowed them to suggest new ideas which were often acted on. The deputy manager had formally sought feedback from people, their relatives and visitors. Their opinions had been captured, and analysed to promote and drive improvements within the service. Stakeholders had not been formally asked for their opinions of the service. Informal feedback from people, their relatives and healthcare professionals was encouraged and acted on wherever possible.

The provider is required by law to notify the Care Quality Commissions (CQC) of incidents that occur at the service. The provider had not notified CQC of some of the incidents that had happened at the service like serious injuries.

We found a number of breaches of 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.

We saw that peoples care plans had been signed and they told us that they were familiar with their plans and knew what was in them. We found that the plans of care and support were written in a person centred manner, focused on people's individual assessments and contained detailed information of their needs.

Staff we spoke with were knowledgeable about people's routines and choices and they knew how to support people effectively. We saw documentation which showed that staff had received the necessary and relevant training to be able to carry out their roles.

The manager told us that they had undergone a refurbishment programme which was near to completion. We found the home to be clean and well maintained.

We saw documentation which showed that systems were in place to enable the health, welfare and safety of the people who used the service to be monitored effectively by the provider.

People said that they were happy with the care and support they received and that their needs were being met in all areas. They said that the staff treated them with respect, listened to them and supported them to raise any concerns they had about their care. People told us that the service responded to their health needs quickly and that the manager talked to them regularly about their plan of care and any changes that may be needed.

Many comments received were complimentary of the service. One person said 'It's very nice here' another said 'The staff are very good. I'm happy to talk about any concerns'. Other people were complimentary of the food and had no concerns regarding the quality of care.

Despite this we found that people were not protected against the risks associated with medicines because the provider had not taken appropriate steps to manage medicines in accordance with guidance and ensure they were stored appropriately.

People living within the service did not benefit from living in an adequately maintained service. Maintenance and renewal programmes were not being carried out in a timely manner which had impacted on the building and resulted in a poor environment.