The Grange Nursing Home

The Grange Nursing Home is a care home providing personal and nursing care for up to 23 people, some of whom were living with dementia. At the time of our inspection there were 21 people using the service.

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

People were safe from the risk of abuse. Risks to people were assessed and regularly reviewed when people's needs changed. The building was well maintained, and health and safety risks were assessed.

Medicines were managed safely. The provider employed sufficient staff, staff were trained appropriately and recruited safely. Staff worked effectively with visiting professionals. Infection control measures were in place, and visiting was managed safely.

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.

Care records were person centred. People were supported to eat and drink a balanced diet. The management team worked in partnership with healthcare professionals to ensure people received appropriate support in a timely manner.

There was a positive culture in the service. Staff said the management team were supportive. People and relatives thought the service was managed well. Quality assurance checks were taking place, lessons had been learnt and improvements were made continuously.

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 7 July 2022).

At our last inspection we recommended that the provider ensured staffing levels were adequate, the home environment was updated and a more effective management and communication structure was implemented. At this inspection we found improvements had been made in all areas.

Why we inspected

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

This report only covers our findings in relation to the key questions safe, effective and well-led. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

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

Follow up

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

The Grange Nursing Home provides nursing and residential care for up to 23 older people, some of whom are living with a dementia related condition. The home is an adapted and extended building with rooms on the ground and first floors. The home has a lift for access to the first floor. There are shared toilet and bathroom facilities and several communal areas around the home. There were 22 people living at the home at the time of our inspection.

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

People told us there were enough staff to help them with their care needs. Staff told us at busy times the home would benefit from more staff. We have made a recommendation about this.

People were supported to take their medicines in the right way at the right time. Where people needed to have creams and lotions applied these were done appropriately. Risks were assessed and managed. People were protected from the risk of infections and staff followed Covid-19 guidance and used PPE appropriately. The provider had learned lessons from the previous inspection and introduced a number of changes and organisational improvements.

Relatives and staff said the environment of the home needed updating and redecorating. A professional said some areas of the home could be better adapted to help people living with dementia. We have made a recommendation about this. Staff had undertaken a range of training although there remained some areas that needed to be completed. Additional staff development was planned to help them better support people’s needs. People were supported with their eating and drinking. We spoke with the manager about how people could be better supported, and their dignity enhanced. People were supported to live healthier lives and access a range of health services.

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

Improvements to the management and monitoring of the service had been made, although the provider acknowledged there was still further work to be done. People and relatives felt there was a need for consistent management. Staff felt there were still improvements needed to help increase staff morale and ensure they received good and timely support. We have made a recommendation about this. A professional told us the manager was approachable, responded to suggestions and had the interests of people living at the home at heart. Some processes were in place to engage with staff and people, although further work was required as the home emerged from the pandemic. People’s wellbeing was supported through the home working in partnership with a range of other services.

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 7 January 2022).There were breaches of regulation in relation to safe care and treatment, fit and proper persons employed, staffing and good governance. We issued a warning notice and told the provider they needed to improve. The service remains rated requires improvement. This service has been rated requires improvement for the last three consecutive inspections.

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, although further work to sustain improvement was required.

Why we inspected

We undertook this focussed inspection to check whether the Warning Notice we previously served in relation to Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met. We also followed up on other actions we told the provider to take at the last inspection. The inspection was further prompted in part due to concerns received about staffing, nutrition, cleanliness and management of the home. A decision was made for us to include those concerns in our inspection and examine those risks. This report only covers our findings in relation to the key questions, safe, effective and well-led, which contain those requirements. We found no evidence during this inspection that people were at risk of harm from these concerns.

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

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

Recommendations

We have made recommendations in the safe, effective and well led sections relating to the review and implementation of best practice guidance. Please see the full report for further details.

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.

The Grange Nursing Home provides nursing and residential care for up to 23 older people, some of whom are living with a dementia related condition. The home is an adapted building with rooms on the ground floor and the first floor. There are shared toilet and bathroom facilities and several communal areas around the home. There were 21 people living at the home at the time of our inspection.

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

This was a targeted inspection that considered safe, effective and well led. Based on our inspection of these three areas we found people were not always supported to receive their medicines in a timely and appropriate manner. Staff recruitment was not always safe, and the provider had failed to carry out full checks before staff began working at the home. There had been improvements in infection control and staff use of personal protective equipment (PPE), although records relating to these areas were not robustly completed. Staffing levels were an ongoing issue for the provider and the numbers of staff on duty did not always meet people's assessed level of need. People and relatives told us staff worked hard to ensure their care needs were met.

People were not always supported by staff who had received up to date training and support. Training records were poorly maintained meaning it was not clear staff had completed important training. Checks that staff were following procedures and guidance were not regularly undertaken. People were supported to access health and social care services to maintain their wellbeing.

Oversight of the quality and safety of the service was not well managed or monitored. Records and documents were not well maintained, and we found gaps in some important areas. The provider and their representative had failed to identify serious omissions around medicines administration and staff recruitment and training. A new manager was in post and had introduced some improvements and changes, but this was at an early stage.

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.

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 22 April 2021) when there was one breach of regulations and we took enforcement action around infection control by imposing conditions on the provider’s registration. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection whilst we found some improvements had been made there were additional concerns and further new breaches of regulations.

The last rating for this service was requires improvement (published 22 April 2021). The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

This was a focussed inspection to review whether the provider had met the conditions we had previously imposed on their registration. We initially looked at the safe and well-led domains. However, during the inspection we also incorporated the effective domain into the inspection process.

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

You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to the safe management of medicines, staff training, recruitment, record keeping and management oversight of the service.

Please see the action we have told the provider to take at the end of this report.

We issued a warning notice to the provider in relation to management oversight and quality monitoring of the service. We have specified a date when we expect the provider to be compliant with this notice and improvements made.

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

The Grange Nursing Home provides nursing and residential care for up to 23 older people, some of whom have a dementia related condition. There were 21 people living at the home at the time of our inspection.

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

We identified shortfalls with infection control. Government guidance in relation to the safe use of PPE was not always followed. In addition, some areas of paintwork, flooring and furniture were not intact and therefore difficult to keep clean.

A system was in place to assess and monitor infection control which had been updated and amended in response to the COVID-19 pandemic. However, the systems and procedures in place were not always followed by staff. We have made a recommendation about this.

Safeguarding and whistleblowing procedures were in place. However, several staff raised concerns of a safeguarding nature, some of which were historical. We referred these to the local authority safeguarding team and notified the registered manager and provider. We have recommended that the provider revisits safeguarding and whistleblowing procedures with staff, so the correct procedures are followed and any concerns are reported in a timely manner.

Processes were in place to involve people and staff in the running of the home. Some staff said the registered manager was, "Too nice." They explained that on occasions, certain issues which they raised, were not fully resolved, because staff said she did not like to cause offence. We discussed this feedback with the registered manager and they explained that all issues raised with them were investigated and addressed.

Staff said that the culture at the home was not always positive and staff did not always work together effectively as a team. We have recommended that the provider keeps the day-to-day culture under review to ensure action is taken if any concerns are raised. The registered manager and provider were aware of the cultural issues at the home and action was being taken to address these.

There were enough staff deployed to meet people’s needs. Medicines were managed safely.

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 (published 12 March 2020)

Why we inspected

We received concerns in relation to people’s care and treatment, infection control and the environment. As a result, we undertook a focused inspection to review the key questions of safe and well-led.

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

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the safe and well led key sections of this full report.

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 Nursing Home on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so

We identified one breach of the regulations relating to safe care and treatment. 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 work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The Grange Nursing Home provides nursing and personal care for up to 23 older people. There were 22 people living at the home at the time of the inspection, some of whom had a dementia related condition. Accommodation was spread over two floors.

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

People and relatives spoke positively about the home. One person told us, “I would give this place 10 out of 10, it’s just a nice place to be. I can’t think of anything they don’t do well.”

There were systems and procedures in place to help keep people safe. Sufficient staff were deployed to meet people’s needs. There was a positive approach to safety and risk which was not restrictive for people. Checks were carried out to make sure the building and equipment were safe. Further safety measures were implemented following our inspection with regards to the premises. Medicines were managed safely.

People were supported by staff who were trained to meet their needs. People and relatives spoke positively about the skills of staff. Comments included, “They do everything really well” and “Staff are very competent at what they do.” The service worked in partnership with other organisations and was involved in research projects to help ensure the home kept up to date with new developments and best practice.

People were supported to eat and drink enough to help maintain their health and wellbeing. People were complimentary about the meals provided. One person told us, “I always have enough to eat, cooked breakfast if I want it…There is enough to eat and drink in between meals too.”

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. The registered manager was strengthening their documentation relating to mental capacity to ensure it accurately reflected how the Mental Capacity Act [2005] was followed.

People were treated with kindness and their dignity and independence was promoted. We noticed positive interactions, not only between care workers and people, but also other members of the staff team such as domestic and kitchen staff. People were supported at the end of their life to be as comfortable as possible. Staff followed a multi-disciplinary approach with health and social care professionals to ensure consistent and responsive care was provided at this important time in people’s lives.

People had care plans which guided staff on how to deliver person-centred care. People’s social needs were met. There was an activities programme in place. There was a complaints procedure in place. None of the people or relatives we spoke with raised any complaints or concerns. Records did not fully evidence how the complaints procedure was followed with regards to one of the complaints received. The registered manager told us this would be addressed.

There was a positive atmosphere in the home. One person told us, “It’s very happy and peaceful here – lovely.” Audits and checks were carried out to monitor the quality and safety of the service. During the inspection we identified several shortfalls with the environment, MCA and complaints. We did not identify any impact of these shortfalls upon people’s health and wellbeing. However, the provider’s quality monitoring system had not identified these issues. We have made a recommendation about the provider’s quality monitoring system.

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 (published 18 August 2017).

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.

We last inspected the care home in May 2016 and rated the service as requires improvement and identified a breach of the regulation relating to safe care and treatment. People who required support with moving and handling could not currently have a bath or shower because the bathroom was being modernised and adapted and fire instruction had not been carried out at regular intervals for night staff.

This comprehensive inspection took place on 11 July 2017 and was unannounced. Two further announced visits were carried out on 14 and 21 July 2017 to complete the inspection. At this inspection we found that action had been taken with regards to the breach and the provider was now meeting all the regulations we inspected against.

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 and associated Regulations about how the service is run. The provider’s main director was the nominated individual and oversaw the management of the service.

Prior to and during our inspection, we received information of concern relating to one person’s care and the management of the service. We took this information into account whilst planning and carrying out our inspection. Throughout this report, we state that people and the majority of relatives told us the service was safe, effective, caring, responsive and well led. This was due to the concerns we received which related to each key question. We checked the specific issues raised and examined other important sources of information outlined in the background section of this report to complete our inspection and support our judgements and ratings. The concerns raised in relation to this one person’s care are being dealt with outside of this inspection process.

We received mixed feedback from people, relatives and staff about whether there were sufficient staff deployed. We spent time observing the care which was provided in the late afternoon/early evening. This period of time was very rushed and several people had to wait for assistance. We have made a recommendation that the provider reviews staffing levels to ensure that staff are deployed to meet people’s needs in a timely manner.

We checked staff recruitment. We noted that two staff had a Disclosure and Barring Service [DBS] Adult First check in place. This had been obtained to ensure they were not barred from working with vulnerable people; however their full check with details of any possible cautions and convictions had not been received at the time of their employment. We noted that a risk assessment had not been completed with regards to this issue. The registered manager addressed this immediately.

Checks and tests had been undertaken to ensure that the premises were safe. Fire safety checks and instruction had been carried out. Action had been taken to ensure the environment was suitable for people with a dementia related condition. The main bathroom had been refurbished and fully adapted.

There were safeguarding procedures in place. Staff were knowledgeable about what action they should take if abuse was suspected. The local authority safeguarding team informed us there were no organisational safeguarding concerns regarding the service.

Medicines were managed safely. This included the management of controlled drugs which require stricter controls because they are liable to misuse.

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.

Records confirmed that training was available to ensure staff were suitably skilled. Staff were supported though an appraisal and supervision system.

People's nutritional needs were met and they were supported to access healthcare services when required.

We observed positive interactions between staff and people who lived at the service. Staff promoted people's privacy and dignity. There were systems in place to ensure people were involved in their care and support.

Care plans were in place, which detailed the individual care and support to be provided for people. Arrangements for social activities met people’s individual needs.

There was a complaints procedure in place. One family had requested a copy of the complaints procedure to make a formal complaint.

Audits and checks were carried out to monitor the quality of the service. There was a system in place to manage people’s monies. The manager had difficulty in locating certain receipts which were eventually found. We have made a recommendation that the provider reviews its recording system for the management of people’s monies.

The provider had notified CQC of all events and changes at the service in line with legal requirements.

Further information is in the detailed findings below.

The Grange Nursing Home provides care to a maximum of 23 older people, some of whom have a dementia related condition. There were 21 people living at the home at the time of the inspection.

We carried out a comprehension inspection in November and December 2015 where we found multiple breaches of the regulations. We rated the Grange Nursing Home as 'Inadequate' and placed the service in 'Special measures.' Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

After the comprehensive inspection, the provider wrote to us to say what action they were taking to meet legal requirements.

We inspected the service again on 26 May 2016 to check that action had been taken. We found that significant improvements had been made in many areas of the service, although further action was required regarding the premises, documentation relating to the Mental Capacity Act 2005 and care planning. In addition, we had not been notified in a timely manner of one person’s injury which had required hospital treatment.

The previous registered manager had left the service. There was a new manager in post who commenced employment in February 2016. He was not yet registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

People who required support with moving and handling could not currently have a bath or shower because the bathroom was being modernised and adapted. Fire instruction had not been carried out at regular intervals for night staff.

We checked medicines management. Staff were currently administering medicines from their original packaging. The manager told us that because of some minor omissions and anomalies he had requested that their pharmacy supplier provide medicines in a monitored dosage system. He explained that this would highlight any errors in a timelier manner.

There were safeguarding procedures in place. Staff knew what action to take if abuse was suspected. They were fully aware of the whistle blowing procedure. External whistle blowing training had been booked in June 2016.

Safe recruitment procedures were followed. We found gaps in the employment history for one staff member. The manager was able to give us an explanation for the gaps and told us that this information would be added to the staff member’s interview record. No concerns about staffing levels were raised by people or relatives. We observed that staff carried out their duties in a calm unhurried manner.

The manager provided us with information which showed that staff had completed training in safe working practices and to meet the specific needs of people who lived there, including dementia care and Parkinson’s disease training.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS) and to report on what we find. MCA is a law that protects and supports people who do not have ability to make their own decisions and to ensure decisions are made in their ‘best interests’ it also ensures unlawful restrictions are not placed on people in care homes and hospitals. 18 applications had been submitted to the local authority to authorise in line with legal requirements. The manager told us that these had not been authorised yet. This was confirmed by the administrator of the local authority DoLS team. Mental capacity assessments were now in place. We saw that some of these were not decision specific. The manager told us that this was being addressed.

We observed that staff supported people with their dietary requirements. An additional member of kitchen staff was on duty over the tea time period. Staff told us that this was appreciated because it gave them extra time to ensure people had a positive meal time experience, since they no longer had to prepare the meal at tea time.

Staff who worked at the home were knowledgeable about people’s needs. We observed positive interactions between people and staff. People were supported with kindness and care.

Care plans were in place which gave staff information about how people’s needs were to be met. Staff were in the process of changing to new documentation which they said was clearer and more person centred.

There was an activities coordinator employed to help meet the social needs of people. People told us that there was enough going on to occupy their attention. This was confirmed by our own observations. There was a complaints procedure in place. Feedback systems were in place to obtain people’s views. Meetings and surveys were carried out.

The service had been through a period of change and unsettlement since our previous inspection. Staff informed us that morale had improved since the new manager had taken over.

There was currently no nominated individual overseeing the management of the service. The previous registered manager had also been the nominated individual. A nominated individual represents the provider and has responsibility for supervising the way that the regulated activity is managed. Following our inspection, we were informed that one of the directors would become the nominated individual.

A new quality assurance system was in place which effectively highlighted any areas for improvement.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This related to safe care and treatment. You can see what action we told the provider to take at the back of this report.

We commenced our inspection on 27 November 2015. The inspection was unannounced which meant that staff and the provider did not know that we would be visiting. We visited the service out of hours at 6.30pm on the first day of our inspection. We carried out three further visits to the home on 3, 4 and 7 December 2015 to complete the inspection.

The home was last inspected in March 2015. We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to consent to care and treatment; management of medicines; safety and suitability of premises and assessing and monitoring the quality of service provision. The provider submitted an action plan which stated what action they were going to take to improve in these areas. They stated that the actions and improvements would be completed by July 2015.

At this inspection, we found that the registered provider had not followed their plan and legal requirements had not been met.

The Grange Nursing Home is situated in Warkworth, Northumberland and provides accommodation for up to 23 older people who require nursing or personal care. There were 22 people living at the home at the time of our inspection.

There was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons.’ Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

Some staff raised concerns about how a recent incident had been dealt with. The manager confirmed that the correct procedures had not been followed and she had not notified the person’s care manager or ourselves. We are investigating this incident and will report on any action once it is complete.

Following our inspection, the local authority’s safeguarding adults team carried out their own investigation into this incident. Allegations of neglect against the registered manager were upheld.

We found that systems to protect people from the risk of abuse were not fully in place. We had not been notified of one safeguarding incident. We found the provider had not taken appropriate action to fully protect people following the recent incident.

We checked the premises and saw that some of the window restrictors which had been fitted to upstairs windows did not conform to the Health and Safety Executive (HSE) design guidelines. These could be overridden and the windows opened fully. Following our inspection, the provider informed us that this had been actioned.

The adaptation, design and decoration of the premises did not fully meet the needs of people who lived with dementia.

There were no designated sluice facilities and staff were manually washing continence equipment in an unused bathroom on the first floor. This procedure increased the risk of cross infection.

Nine of the 13 people who used bed safety rails to reduce the risk of them falling out of bed did not have any bed rail bumpers fitted [protective padding]. This omission meant that people were not fully protected from the risk of injury.

Staff told us that prior to our visit they transferred some people to the shower room using shower chairs. It was not clear whether the shower chairs were designed for the transportation of people around the home. One shower chair had been disposed of following the serious incident and the other shower chair had been stored in the loft. The maintenance man told us that checks had not been carried out to ensure the safety of the shower chairs. This meant that equipment used in people’s care had not always been assessed as being appropriate or safe.

There were shortfalls in the management of medicines. One person had been given an incorrect dosage of Warfarin, a medicine used to prevent blood clots. We found that it was not always possible to ascertain whether people had had their medicines as prescribed.

We found shortfalls in the recruitment records we checked. These did not always document fully the recruitment checks and decisions which had been undertaken.

Staff told us that there were sufficient care staff to support people. They told us however, that more support would be appreciated at tea time since kitchen staff left at 2.30pm and they had to organise the tea time meal.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS) and to report on what we find. MCA is a law that protects and supports people who do not have ability to make their own decisions and to ensure decisions are made in their ‘best interests’ it also ensures unlawful restrictions are not placed on people in care homes and hospitals. The manager had submitted DoLS applications to the local authority to authorise. We found however, that decision specific mental capacity assessments were not in place to document decisions such as those relating to people’s finances, health checks and restrictions such as bed rails. The manager was unaware of mental capacity assessments.

Some staff told us that they felt supported; others told us that more support was required. We read supervision records and found some inconsistencies and irregularities regarding the dates when these sessions had been held. This meant that it was not possible to ascertain whether staff were provided with the appropriate support and that supervision sessions were carried out as planned.

Staff told us that training was available. The manager provided us with information about staff training. We had concerns about moving and handling procedures and found that there was no designated moving and handling coordinator to advise on moving and handling procedures at the home.

We observed the tea time period and noticed that discreet support was provided and people told us that they enjoyed their meals at the home. There were shortfalls however, with two people’s care plans which we viewed in relation to their dietary requirements.

We observed that care was provided with patience and kindness. Although we discovered that people were transferred to the shower room in a way which did not promote their privacy and dignity.

An activities coordinator was employed to help meet the social needs of people who lived at the home. People and relatives told us that activities provision was good at the home.

The manager carried out audits on a number of different areas of the home including care plans, medicines and infection control. It was not always clear what actions had been taken in relation to any shortfalls identified. We noted that “quality assurance” and “food” questionnaires were undertaken to ascertain the opinions of people and their representatives. We saw however, that these were not dated and there was no overview of the findings.

We found serious shortfalls in the maintenance of records. We found irregularities, inconsistencies and factual inaccuracies in some of the records we viewed relating to people’s care, records relating to staff and those relating to the management of the service. Following our inspection, we wrote to the provider using our regulatory powers to request further information that we were unable to obtain during our inspection.

Since April 2015, adult social care providers have to comply with the Duty of Candour regulation. This regulation states that providers must be open and transparent with people and those acting lawfully on their behalf about their care and treatment, including when it goes wrong. Some staff and a relative felt that there had been a lack of openness and transparency regarding one particular incident. We also found inconsistencies and irregularities with regards to information we received from the manager and the records we viewed during the inspection in relation to this accident

.

We found that neither the provider or manager had not notified us of one safeguarding incident. In addition, we had not been informed about one serious injury. The submission of notifications is required by law and enables us to monitor any trends or concerns and pursue any specific matters of concern with the provider.

At this inspection, we found concerns with many aspects of the service. This meant that the provider did not have effective systems in place to ensure they were able to meet the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures.’ Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

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

The premises provided people with a clean and comfortable place to live and were in a good state of repair.

We looked at equipment and facilities provided for the people who used the service. We found people were provided with appropriate equipment which was well maintained to ensure their safety.

We found there were sufficient staff on duty at all times to meet people's current needs. This was confirmed by the people who used the service, their visitors and the staff.

People were asked their views about the service and these were taken into account. The provider had systems in place to monitor care delivery and ensure the health, safety and welfare of people who used the service was maintained.

People told us they were happy living there. Comments included, 'It's not bad here' and 'It's very pleasant'.

Visiting relatives told us, 'It's like a five star hotel. (The staff are) approachable local girls who provide a home from home.'

We found people were treated with dignity and respect. One person spoke highly of the care and support provided, which meant she would be able to return to her own home to live independently.

People's care and support needs were appropriately assessed and their care was planned and delivered in line with their individual support plans. People were involved in making decisions about their care and their views were sought regularly. A visitor told us, 'Nothing is done without discussion.'

We found people were protected from the risks of inadequate nutrition and dehydration. People liked the food. They told us, 'There's a good range of home cooked food.'

The premises were clean and in a good state of repair.

Appropriate checks had been made before staff began work. People told us, 'They are lovely, marvellous staff. I can't speak highly enough of them.' A visitor said the staff were 'tip top.'

People were aware of the complaints system and told us the manager was always approachable. They told us, 'Everything is fine here.'