Archived: The Grange

At the time of our inspection there was no registered manager in post. The registered manager had applied to de-register with the Care Quality Commission. There was an interim manager who was in the process of completing an application to 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 our last comprehensive inspection on 27 September 2016. We found nine breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to seeking consent, safe care and treatment, safeguarding service users from abuse and improper treatment, good governance, fit and proper person, failure to manage risks of malnutrition effectively, and failure to send notices of change and other incidents. We issued two warning notices in relation to the breaches of regulations relating to safe care and treatment and good governance. We asked the provider to achieve compliance by 22 December 2016.

We undertook a focused inspection on 22 February 2017 to check that the provider had followed their plan and to confirm that they met legal requirements following enforcement action. The focused inspection covered the safe and well led domains only. The provider met the requirements for these two domains. However there were remaining breaches in relation to the management of people’s nutrition, safeguarding service users from abuse and improper treatment, seeking consent and staff training and supervision. These issues were monitored as part of this inspection.

During this inspection on 31 July 2017 we reviewed what actions the provider had taken to improve the service. We saw that significant work had taken place since our last inspection to improve the safety, effectiveness and quality of the service. The provider had met the requirements in relation to seeking consent, staff training, managing people’s nutrition and safeguarding people from abuse and improper treatment. Further improvements were required in respect of medicines management.

Feedback from people and their relatives regarding the care quality was positive. Views from all the visiting professionals we spoke with were positive.

People who lived at The Grange told us that they felt safe and there was sufficient staff available to help them when they needed this. Visitors and people who lived at the home spoke highly of the provider and care staff. They told us that they were happy with the care and treatment.

There were up to date policies and procedures in use by staff.

We saw copies of satisfaction surveys that had been completed by relatives and people who lived at the home. The majority of these surveys demonstrated people thought their care and the staff who supported them were excellent.

We looked at how the service protected people against bullying, harassment, avoidable harm and abuse. We found there were policies and procedures on safeguarding people. Staff had received up to date training in safeguarding adults; they showed awareness of signs of abuse and what actions to take if they witnessed someone being ill-treated.

Safeguarding incidents had been reported to the relevant safeguarding authority. Staff had documented the support people received after incidents. Staff had sought advice from other health and social care professionals where necessary. There were risk assessments which had been undertaken for various areas of people’s needs. Plans to minimise or remove risks had been written and reviewed.

The level of staffing on the day of the inspection was sufficient to ensure that the current number of people who lived at the home had their needs met in a timely manner. Systems were in place for the recruitment of staff and to make sure the relevant checks were carried out before employment.

Improvements had been made in respect of staff training and development. Staff had received regular training in various aspects of health and social care. Records for medicines and audits had been completed appropriately. However people did not have plans of care for ‘as required medicines’, we discussed this with the interim manager who rectified this immediately.

People were protected against the risk of fire. Staff had received fire safety training and regular fire safety inspections had been undertaken. The building fire risk assessment had been kept up to date and fire equipment serviced in line with related regulations.

There was an infection control policy and the environment had been kept clean. People’s bedrooms were personalised to their tastes to reflect their choice. The provider had made attempts to ensure the environment was suitable for people living with dementia however this was work in progress and more work was due to be done.

The systems used in the recording of information about seeking people’s consent and undertaking mental capacity assessments when the planning for their care had improved since our last two inspections. We found care planning was done in line with Mental Capacity Act 2005 (MCA). Staff had received mental capacity training and the majority of the care staff showed awareness of the MCA and how to support people who lacked capacity to make particular decisions. Improvement of staff knowledge was needed to demonstrate how they can apply the MCA in their day to day roles.

People who lived at the home had access to healthcare professionals as required to meet their needs.

There were improvements in staff training and development. Staff had received induction and appraisals. However improvements were required to ensure all staff had received supervision and to ensure there was a system for monitoring when staff were due for their supervision. Feedback from staff regarding the training was positive.

We found improvements in the way care plans had been written and organised. Care records were written in a person centred manner. People who lived at the home and their relatives told us they were consulted about their care. The provider had sought people’s opinions on the quality of care and treatment being provided. This was done through relatives and residents meetings and annual surveys.

There were improvements in the way people were supported against the risks of malnutrition and weight loss. Risks of malnutrition and dehydration had been assessed and monitored. Where people's health and well-being were at risk, relevant health care advice had been sought so that people received the treatment and support they needed.

People were supported with meaningful daytime activities. However, there were limited meaningful activities on the morning of the inspection. The provider was in the process of employing an activities co-ordinator.

The provider had continued to improve the management systems in the home. Internal audit and quality assurance systems were in place. These had been implemented to assess and improve the quality of the service and to proactively identify areas of improvement. Care files, staff files, medicine administration records and environmental checks had been audited.

The visions and values of the service had been shared with staff, people and their relatives. We received mixed feedback from staff and relatives regarding management. Staff we spoke with told us they enjoyed their work however they did not feel they could share their views regarding the quality of the service or care and feel listened to. We shared the feedback with the provider. Staff surveys had been carried out however staff informed us they were not confidential and they could not fully express their views.

There was a contingency plan to demonstrate how the provider would respond to eventualities which may have an impact on the delivery of regulated activities.

People and their relatives felt they received an excellent service and spoke highly of the staff. They told us the staff were kind, caring and respectful and that their dignity privacy and confidentiality was maintained.

We found the service had a policy on how people could raise complaints about care and treatment and one complaint received had been dealt with appropriately.

We issued two warning notices in relation to the breaches of regulations relating to safe care and treatment and good governance. We asked the provider to achieve compliance by 22 December 2016.

We undertook this focused inspection on 22 February 2017 to check that the provider had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to the requirements for safe care and treatment and good governance. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for The Grange on our website at www.cqc.org.uk.

The Grange is a residential care home for adults living with dementia and /or complex mental health needs. It has 22 single rooms and two twin bedded rooms on two floors. There is a lift to access the second floor. There are a number of communal areas as well as a garden area to the rear. The Grange is located near Chorley town centre. It has a car park and the front entrance has a ramp.

At the time of our inspection there was no registered manager in post. The registered manager had applied to de-register with the Care Quality Commission. There was an interim manager who was in the process of completing an application to 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.

During this inspection we found that the provider had made improvements in relation to safe care and treatment and good governance and legal requirements were being met.

People who lived at the home and their visitors told us that the quality of care had improved since our last inspection. They told us that they felt safe and that management were closely involved in the day to day running of the service. Visiting professionals also supported this view and gave positive feedback.

Training records indicated that all staff had now had training on safeguarding people from abuse. All the staff we spoke with knew the appropriate action to take if they believed someone was at risk of abuse and were aware of the procedures for reporting bad practice or ‘whistle blowing’ within the organisation.

Accident and incidents had been recorded and analysed and where necessary reported to safeguarding authorities.

Since the last inspection in September 2016 a new pharmacy system had been introduced into the home and this had led to an improvement in the management of the medicines. Staff had also received medicines management training. Medicines were being stored and recorded appropriately including controlled drugs (medicines subject to tighter controls because they are liable to misuse). There were up to date policies and procedures in use by staff. Appropriate procedures were in place for the ordering and disposal of medicines.

Since the last inspection the provider had been responsive and proactive in improving the systems used in the recording of information about people’s needs and the planning of their care. We looked at the risk assessments in place for people and these included risk assessments for skin and pressure area care, falls, moving and handling, mobility and nutrition and for the management of a different conditions or specific medication. We looked at the risk assessments in place and how people would be supported in the event of fire. These had been introduced and kept under review.

The level of staffing on the day of the inspection was sufficient to ensure that the people who lived in the home had their needs met in a timely manner. The numbers of staff on shift during the day and night were seen to be consistent. Systems were in place for the recruitment of staff and to make sure the relevant checks were carried out before employment.

We saw that systems to assess the quality of the services in the home had improved significantly. There was a programme in use to monitor or ‘audit ‘service provision to identify areas of weakness and address them. However, we found a lack of people’s involvement in the planning and future of the service.

People were not always consulted on how they wanted the service to be delivered.

The service was last inspected on 12 November 2013 and was found to be meeting the regulations applicable at that time.

During this inspection we found the service to be in breach of the Health and Social Care Act, 2008 (Regulated Activities) Regulations 2014 in relation to, seeking consent, safe care and treatment, safeguarding service users from abuse and improper treatment, good governance, staffing, failure to manage risk of malnutrition effectively, failure to send notices of change and other incidents. You can see what action we told the registered provider to take at the back of the full version of the report.

The registered manager was not present throughout our inspection however, one of the members of the partnership operating the home was present. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated regulations about how the service is run.

At the time of this inspection 23 people were using the service. We spoke with five of these people and three of their relatives. We asked people for their views about the services and facilities provided. We received some positive comments from those we spoke with. People who lived at the service and their relatives told us that they felt safe.

We looked at how the service protected people against bullying, harassment, avoidable harm and abuse. We found that staff had received training in safeguarding adults. They showed awareness of signs of abuse and what actions to take. However, we found the home had not reported to the local safeguarding team and Care Quality Commission (CQC) when people had suffered serious and unexplained injuries. We asked the provider to report all incidents to the local authority immediately after the inspection. There was no record of safeguarding incidents and how they had been analysed for trends and patterns.

The provider had recorded accidents and incidents and documented the support people were getting after experiencing falls. However, staff had not sought advice from health professionals in all instances especially, incidents involving unwitnessed falls and head injuries. Risk assessment had been undertaken during assessments and plans to reduce risks had been drawn and reviewed in line with the organisation’s policy. However, we found one person’s file did not have a review after two significant incidents which resulted in serious injuries.

We found people’s medicines had not been managed in a robust manner. This included the storage and administration practice that we observed. People did not have care plans for ‘as and when’ medicines (PRN). Staff had received medicines training; however, they had not been competence tested to ensure they were administering the medicines as recommended. We found one person was being given medicines that they had not been prescribed and belonged to another person. We informed the home this was unsafe practice that was not acceptable and to report this as a safeguarding incident. In addition to this we observed unsafe medicine administration practices from the manager during the inspection.

Building fire risk assessments were in place; however, people did not have personal emergency evacuation plans (PEEPS) to enable safe evacuation in case of emergency and care staff had not received fire safety training.

Infection control measures were in place and standards of hygiene had been maintained. However, the service had not provided the appropriate bins for disposal of clinical waste which caused a risk of cross contamination.

We found concerns regarding safe recruitment of care staff. Three of the seven care staff files we looked at showed care staff had been employed without suitable references. One member of care staff had employment gaps on their application form, these had not been explained and the provider had no system or processes for checking whether care staff had convictions once they had been employed by the service. This was against the organisation’s own policy.

On the day of inspection the service had adequate care staff to ensure that people's needs were sufficiently met. People who lived at the home, relatives and care staff expressed they were happy with the level of staff and did not have to wait long periods of time for help.

We found people’s care plans had not been written in line with the Mental Capacity Act, 2005 (MCA). People’s consent to receiving care was not recorded in their care files. Staff had not received mental capacity training. This was evident when speaking with staff. Knowledge of mental capacity among staff needed some improvement and the registered provider had limited awareness of the principles of the Mental Capacity Act and how to apply them in practice. Appropriate applications for Deprivation of Liberty Safeguards had not been made for 18 people who were deprived of their liberties.

There was a significant shortfall in mandatory staff training. Staff competences were not checked regularly in various areas of practice including moving and handling and medicines administration.

People using the service had access to healthcare professionals as required to meet their needs. We found that people’s health care needs were assessed on admission to the service to ensure the home was able to meet their assessed needs. However, one person had no care plan to show what their needs were and how the home was meeting those needs.

Care plans did not demonstrated people’s involvement. People and their relatives told us they were consulted about their care however; they were not involved in regular reviews of their care.

The service could not demonstrate how they sought people’s opinions on the quality of care and service being provided. There were no relatives and residents meetings or regular surveys to seek people’s views and opinions about the care they received.

People were offered adequate food and drinks throughout the day ensuring their nutritional needs were met. Where people's health and well-being were at risk, relevant health care advice had been sought so that people received the treatment and support they needed. However, risks of weight loss were not managed in a robust manner because weight monitoring was inconsistent.

People were supported with meaningful daytime activities however this was not consistent practice. There was no activities co-ordinator and the activity plans were not consistently followed, and staff had not consistently recorded activity records to show what people were doing or had done. On the day of inspection staff were observed to engage people in some activities of their choice. People who were able to access the community independently had been supported to actively have social involvement in the community.

Management systems in the home were not robust. The registered manager was not actively involved in the day to day running of the home. They had not done so for up to 6 months and the provider had not sought a replacement registered manager or informed CQC of the current management arrangements. Staff had not received regular and adequate training to support them in their role. Care staff had not received supervision and recruitment practices had exposed people to risk.

The quality assurance systems were in place however, they were not robust enough as some areas of people’s care had not been audited regularly to identify areas that needed improvement. We found audits had been undertaken for the premises and health and safety however; areas such as infection control, medicines, care plans, staff recruitment files and kitchen had not been audited regularly.

There was no business contingency plan to demonstrate how the provider had planned for unplanned eventualities which may have an impact on the delivery of regulated activities.

The provider was not meeting the Care Quality Commission registration requirements. They did not send notifications to CQC for notifiable incidents, such as serious injuries, and other notifiable incidents including the absence of the registered manager.

We found six instances where the service had not worked in line with its own organisational policies. This included recruitment of staff, staff supervision, care planning, mental capacity, infection control, medicines administration and undertaking criminal record checks on care staff.

People felt they received a good service and spoke highly of their staff. People told us they hardly saw the registered manager. They told us the staff were kind, caring and respectful. Many people appreciated having their privacy and independence. People told us the provider visits the home regularly and was pleasant and approachable.

We found the service had a policy on how people could raise complaints about care and treatment however, there was no evidence to demonstrate how complains had been received and dealt with in line with regulations. Complaints had been dealt with face to face.

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 hav

People commented, 'I am well looked after, no complaints, the staff are really good". "I can generally do most things myself, but I do have a problem with my knees. If I want a bath and a shower I can have one. I think the staff work very hard.' Relatives told us 'They always discuss his care with me.' 'The staff are very good. In fact it's one of the best homes around for the care they provide.'

People had care plans that promoted a person centred approach to their care. Staff were attentive to peoples' request for assistance and were respectful. Staff knew how to care for people at risk of falling, developing pressure ulcers or who may not eat enough.

People lived in a safe environment. They said they were comfortable and had everything they needed. There was sufficient staff on duty to make sure people had the attention they needed.

People were consulted in matters relating to their care and welfare. Quality assurance monitoring showed an overall satisfaction with the service provided, the staff team and the environment. 'What makes the Grange such a good place for your loved ones is purely the staff who are patient, friendly and genuinely caring'. And 'All carers do care and are special at The Grange'.

Their comments included:

'I'm really pleased, my mums a different person since moving here'.

'They care for her, they look after her as well as I could'.

However, one relative told us that there was not enough staff commenting that 'they do seem to be run ragged sometimes, they are not able to give the care and attention, purely down to not enough of them'the patients are expected to sit and listen to music or watch television there's nothing much to do'.

We spoke with four staff members and three of them told us: 'Feel sometimes there's not enough staff' and in terms of having capacity to engage with residents and provide stimulating activities 'sometimes there's not enough going on for them'it only takes one of them to kick off and you can't do anything with them'.