Rothsay Grange

Rothsay Grange is a residential care home providing personal and nursing care to up to 60 people. The service provides support to older people, people living with dementia or physical disabilities and younger adults. At the time of our inspection there were 59 people using the service.

Rothsay Grange is a purpose-built care home providing care to people over 3 floors, 1 of which specialises in providing care to people living with dementia.

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

Improvements had been made in safe management of medicines, governance and staffing and the provider was no longer in breach of regulation.

People were safeguarded from abuse by staff trained to protect them. People felt safe at the service and regular servicing and maintenance ensured the premises were safe. Recruitment was safely completed and agency staff were used to maintain safe staffing levels. Medicines were safely managed and improvements had been made since we last inspected. We were assured the provider maintained good infection prevention and control standards and government guidance was followed both in IPC and around visiting the service.

Most people’s care records contained extensive plans to ensure they received the care they needed, in a way they were happy with. Some care plans needed additional information to enable staff to provide personalised support. Staff completed an induction on commencing in post and completed additional and refresher training to ensure they were familiar with current good practice. People were weighed at least monthly and referrals to healthcare professionals were made should they become necessary. The chef was responsive to people’s needs and wishes and prepared meals people enjoyed. The premises were in good condition and there will be a full refurbishment next year.

People and their relatives told us they were well cared for at Rothsay Grange and they were involved in making choices. They told us they received support when they needed it apart from certain busy times of the day such as first thing in the morning. People were supported to remain active and as independent as possible. 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.

Details were lacking in some clinical care plans but people were involved in devising them if possible. More consideration was needed about escalation of treatment on Recommended Summary for Emergency Care and Treatment ReSPECT forms. There were a wide range of plans addressing aspects of people’s health and well-being and daily activities. People had been supported throughout the pandemic to maintain contact with relatives and friends, and visitors had been able to access the service in line with current guidelines. People could participate in a varied activities programme.

The service was managed in a positive way and staff could access the management team when needed as they had an open-door policy. The provider understood their responsibilities under the duty of candour and informed CQC of significant events in the service. Regular meetings and quality assurance surveys ensured the provider maintained good communications with staff, people and relatives.

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 30 September 2020). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

The inspection was prompted in part due to concerns received about dementia care, lack of staffing, people living with dementia who had behaviours that put others at risk and poor infection control. A decision was made for us to inspect and examine those risks.

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

The overall rating for the service has changed requires improvement to good based on the findings of this inspection.

Follow up

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

Rothsay Grange is a residential care home providing personal and nursing care to 48 people at the time of the inspection. The service can support up to 60 people.

The location is purpose built and delivers care on three floors. One floor is specifically for people living with dementia.

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

There were no specific care plans for mouthcare and records of mouthcare were not maintained.

A new policy and procedure on mouthcare had been planned, however, the pandemic had postponed its introduction.

We made a recommendation about the provision of mouthcare at Rothsay range.

Staff were wearing appropriate levels of personal protective equipment and there were clear instructions for visitors to the premises to follow before entering.

We were assured that the service was working within current infection control guidance.

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 requires improvement (published 1 October 2020).

Why we inspected

We undertook this targeted inspection to check on a specific concern we had about the standard of mouthcare. The overall rating for the service has not changed following this targeted inspection and remains requires improvement.

CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

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.

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

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.

Rothsay Grange is a residential care home providing personal and nursing care to 53 people at the time of the inspection. The service can support up to 60 people in one purpose-built three-story premises. The first floor, Memory Lane, provides more specialist services to people living with advancing dementias.

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

The service was not always safe.

We were not assured that medicines administered were monitored safely and improvements are required.

There were not sufficient staff deployed to maintain peoples safety in all areas of the service, in particular, the Memory Lane floor lacked staff in communal areas meaning people were at increased risk of harm. Improvements are required to ensure there are sufficient staff deployed.

There have been no cases of COVID-19 at Rothsay Grange, however we found that infection prevention and control practice, (IPC), was not always as robust as it should be. We have made a recommendation for the provider to review good practice and government guidance around IPC.

Links to health care professionals had been maintained through the pandemic.

Risk assessments had been completed however we were not assured that risks were effectively managed. We have recommended that the provider reviews practice around managing risks.

People were safeguarded from the risk of abuse by staff trained to identify and report potential concerns.

Accidents and incidents were analysed, and learning was taken from them to minimise future occurrences.

The service was not always well-led. Monitoring of systems such as medicines and care plans did not identify the issues we found. Current good practice and government advice was not always adhered to.

Staff did not always feel supported by the management team however relatives we spoke with were mostly happy with the service provided.

Complaints and concerns were dealt with promptly and there was ongoing work to improve the service.

The provider acted on the duty of candour and was open with relevant partied when things went wrong.

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 4 July 2018).

Why we inspected

The inspection was prompted when we received concerns in relation to the management of medicines, staffing levels, care delivered, how incidents were recorded and use of personal protective equipment, (PPE). As a result, we undertook a focused inspection to examine the risks and to review the key questions of safe and well-led only.

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

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

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

You can also 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 Rothsay Grange 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 monitor the service 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 administration of medicines, staffing and our concern that there was a lack of effective monitoring of some aspects of the service. We have also made recommendations about staffing, risk management and infection prevention and control.

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

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. 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.

There was a registered manager in post. A registered manager 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.

Rothsay Grange provides care and accommodation for up to 60 people who have dementia and / or health conditions. When we inspected there were 34 people living in the home.

The home was purpose built, spacious and equipped to meet the needs of people living there. There were extensive grounds that could be accessed by some people to the front of the premises and a large courtyard garden accessible to all residents.

At the last inspection of this service on 31 March and 1 April 2017 we rated the service as ‘Requires Improvement’. This was due to there still being insufficient staffing deployed to meet the needs of people living in the home and improvements needed in quality audits and responses to complaints. We found at this inspection that improvements had been made in all previous areas of concern and the service had achieved an overall rating of ‘Good’.

There were systems in place to keep people safe and staff had completed training in safeguarding.

A robust recruitment process ensured that only people suitable and qualified to work in a caring role were employed at the service.

Medicines were safely managed. Nurses administering medicines were protected from interruptions during the medicines round.

Staff asked for consent before providing care and understood the Mental Capacity Act (2005) and supported people with decisions if they lacked capacity to make them independently.

Appropriate applications were made to the local authority to deprive people of their liberty.

People were supported with their nutrition and hydration needs, referrals to appropriate healthcare professionals were made and care plans developed to prevent malnutrition.

Staff enabled people to maintain their dignity and provided respectful and empathetic care.

Care plans were person-centred and involved people and their families. These were regularly reviewed and updated according to the changing needs of individuals. Peoples personal histories were in depth and contained contacts for important friends and relatives.

Care was also person-centred. Some people liked staff to be informal and jocular when supporting them, others liked a more formal approach. Staff ensured they addressed people by their preferred name and took the approach requested by them.

End of life care plans were holistic and included details of people’s spiritual needs.

The registered manager and provider completed regular audits to ensure the service was providing safe and good quality care. If there were areas requiring improvement the registered manager worked with the staff team to make improvements.

Staff were not always appropriately deployed, recruitment checks were not robust, arrangements for communicating risk were not effective, medicines were not managed safely, staff did not receive good support and supervision and good systems were not being applied to support people to make decisions. We also found care was not always personalised, end of life care was not effective and people were not supported to manage their pain. Safeguarding concerns were not always reported to the relevant professional organisations. Leadership was inconsistent and quality assurance systems were not effective.

Rothsay Grange provides accommodation and support for up to 60 people who may require nursing and dementia care. At the time of our inspection 35 people were living at the home. The home consisted of three floors. The middle floor, known as Memory Lane, cared for people living with dementia. The ground floor accommodated people with personal care needs. The top floor accommodated people requiring re-ablement and respite care, some of whom had long term care needs.

At this inspection we found significant improvements had been made in many areas. The provider had met five of the six requirements we issued and had taken sufficient steps to meet the warning notice.

However the deployment of staff still requires improvement to ensure people’s needs are met at all times and some relatives told us they were not always satisfied with how their complaints were dealt with. They told us they did not always receive updates when they requested feedback.

Robust recruitment procedures were in place and followed to assess the suitability of staff to work with people.

Good arrangements for the management of people’s medicines were in place. The registered manager had good systems in place to identify any errors and appropriate action was taken when this happened.

Safeguarding concerns were reported appropriately to the local authority and CQC.

Communicating risk relating to particular conditions and behaviours was discussed through effective handover meetings and shared with relevant staff.

The provider had complied with the requirements of the Mental Capacity Act 2005.

Staff at all levels received appropriate support, supervision and competency assessments. Staff had completed training relevant to their role with input from external organisations where appropriate.

People who were at risk of dehydration or malnutrition were monitored effectively. Food and fluid intake records were reviewed daily by the nursing staff and management to check people’s intake.

Guidance was in place to help people manage their pain. Records provided good detail for to use when assessing whether someone was in pain.

People who were at risk of skin damage were supported properly, in line with their care plan and investigations into why skin damage occurred were conducted.

Actions identified through internal quality assurance audits were followed up and closely monitored.

Leadership within the home was open, supportive and transparent.

Relatives, healthcare professionals and people consistently told us staff at all levels were caring.

Documentation detailed information about people’s likes, dislikes, hobbies and interests. Records also provided detail about people’s past including previous jobs, their religious views and different countries they visited.

People were supported with dignity and patience during meal times. Staff were accommodating, understanding and respectful when they helped people with their food and drinks.

We found one 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 this report.

Rothsay Grange provides accommodation and support for up to 60 people who may require nursing and dementia care. At the time of our inspection 49 people were using the service. The home consisted of three floors. The middle floor, known as Memory Lane, cared for people living with dementia. The ground floor accommodated people with personal care needs. The top floor accommodated people requiring re-ablement and respite care, some of whom had long term care needs.

At this inspection we returned to assess whether the provider had made the necessary improvements from our last inspection and to check they met our requirements. We also inspected Rothsay Grange at this time because we had received a number of concerns from relatives and healthcare professionals. They told us people were not receiving the appropriate end of life care and said staff were still not appropriately deployed throughout the home. They told us people were not being supported to look after their skin and said risk assessments and care plans did not always provide staff with robust guidance. We were told of concerns that the leadership in the home was not effective and we were told medicines were not being managed safely or administered at the times people needed them. We were also advised care plans were not in place to assist people who were in pain.

Although some improvements had been made in respect of recruitment and quality assurance, the provider had failed to meet the requirements issued at the last inspection. In addition we identified significant concerns relating to the care and support people received.

The provider did not have sufficient numbers of suitably skilled, qualified and experienced staff deployed at all times to meet people’s care and support needs Staff consistently told us they found it difficult to meet people’s needs and relatives told us they felt staffing levels were unsafe.

Robust recruitment procedures were not always fully applied.

Arrangements for the management of people’s medicines were not always safe.

Safeguarding concerns were not always reported appropriately to the local authority or to CQC. People told us complaints were not always taken seriously or appropriately investigated.

Communicating risk relating to particular conditions and behaviours that challenged others were not always shared effectively. Staff were not consistently provided with good guidance on how to respond to people’s needs.

The provider failed to ensure people’s freedoms were not unlawfully restricted and documentation did not consistently reflect the requirements of the Mental Capacity Act 2005.

Staff at all levels did not consistently receive appropriate support, supervision or competency assessment.

Staff had not always completed training relevant to their role.

People who were at risk of dehydration or malnutrition were not always monitored effectively. Food and fluid intake records were often incomplete.

Assessments and guidance were not in place to help people manage their pain. It was unclear how staff assessed when people were in pain.

People who were ar risk of skin damage were not always supported properly and investigations into why skin damage occurred were not consistently conducted. There was no evidence of action taken to reduce the chance of skin damage happening again.

People’s mental health needs were not always met. There was no guidance for staff on how to support people’s mental health needs.

The emotional needs of people who received end of life care were not always assessed and documented.

Actions identified through internal quality assurance audits were not consistently followed up which resulted in people receiving unsafe care.

Leadership lacked consistency and staff told us constant change created confusion in communication and management of the home

Relatives, healthcare professionals and people consistently told us staff at all levels were caring and provided the best service they could.

Documentation detailed information about people’s likes, dislikes, hobbies and interests. Records also provided detail about people’s past including previous jobs, their religious views and different countries they visited.

People were supported with dignity and patience during meal times. Staff were accommodating, understanding and respectful when they helped people with their food and drinks.

During the inspection visit the provider responded positively and took action quickly when we shared our concerns.

We found six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the Care Quality Commission (Registration) Regulations 2009. We issued a warning notice in relation to Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Safe care and treatment)

The overall rating for this service is ‘Inadequate’ and the service is therefore in 'Special measures'. The service will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, it 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.

You can see what action we told the provider to take at the back of this report.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time. The service was in the process of advertising for a new registered manager.

We observed how staff supported people, and looked at documents including care plans and management reports. People were cared for in units across three floors, depending on the level and type of their needs. For example, staff on one floor cared for people who required nursing care, and on the memory unit they supported people with dementia. This helped to ensure people were provided with care appropriate to their needs.

Information of concern had been brought to our attention regarding staffing levels, and the impact of this on meeting people’s needs. We considered this concern as part of our inspection. We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask; is the service caring, responsive, safe, effective and well led?

This is a summary of what we found.

Is the service caring?

The service was caring. We observed that staff were kind and patient. A relative told us “The best thing [about the service] is the carers. Some are absolute treasures”. We saw staff supported people at their pace when helping them to mobilise and eat. They spoke gently with people, and provided reassurance when they were anxious. An agency care worker told us “Staff have a good relationship with people. They hug them like they are family”.

Is the service responsive?

The service was responsive to people’s needs. We noted that call bells were answered promptly during our inspection, and when people asked for help during mealtimes staff were quick to respond to their requests. One person told us “Staff are willing to help in any way they can, they never grumble. Most of the staff are very nice”.

People’s care plans documented that changes to people’s needs or health had been identified. We saw that referrals to health professionals had been made when required. Care plans included guidance for staff to ensure they understood how to support people in accordance with instructions from health professionals.

Is the service safe?

One person told us “I feel secure here”. Risks affecting people and others had been assessed, and regularly reviewed. This helped to ensure that people were protected from potentially harmful hazards. We noted that staff had been trained in safe procedures to use when supporting people to mobilise and re-position. The operations manager explained that staff competencies were assessed during an induction period to ensure they had the skills required to support people safely.

Concerns had been raised with CQC regarding insufficient staffing levels, and the impact this had on attending to people’s needs. We observed staffing levels during our inspection, and reviewed rotas for the previous two months. The operations manager told us staffing levels had recently been increased, and we saw this reflected in the rotas we looked at. We did not observe delays in attending to people during our inspection. One nurse told us “They are getting there with staffing. Call bells are managed better now”.

Is the service effective?

The service did not always effectively document that people had consented to elements of their care, such as taking medication or receiving vaccinations. We saw that mental capacity assessments had been clearly documented for some people, and indicated whether these people were able to make an informed decision about specific elements of their care or treatment. But for other people, we saw that a best interest decision had been made on their behalf without evidence of an assessment of their capacity to make the decision first. This demonstrated that decisions may have been made on people's behalf without consideration of the legal process to do so.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to gaining people’s consent to care and treatment.

We found that the service effectively managed people’s care and treatment. Assessments ensured that changes to people’s nutritional balance, skin integrity, mental wellbeing and mobility were identified promptly. When changes had been identified, we saw that staff took appropriate actions to ensure people received the care or treatment required to maintain their health and promote their wellbeing.

New staff attended an induction programme that ensured they had the skills and confidence required to support people effectively. The provider’s mandatory training programme ensured that these skills were maintained and refreshed. However, we did not find that staff received regular supervision or annual appraisal meetings, in accordance with the provider’s policy. This meant staff did not always have a formal opportunity to discuss concerns or development on a one to one basis.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to supporting staff.

Is the service well led?

The service was well led. One staff member described the current management arrangements provided by the operations manager as “responsive", and told us the manager was "willing to meet and listen”. They had been in place for one week at the time of our inspection. The manager told us of their plans to improve people’s care and welfare, and provide more support for staff. We noted that the time planned in which to achieve this was focused and constrained to ensure these changes delivered the required results promptly.

We found that the care and welfare of people in relation to their wound care had improved since our last inspection. Record keeping had also improved and therefore the provider had met both of these requirements.

However we found that where people may not have the capacity to consent, the provider had not always acted in accordance with legal requirements.

Although care planning had improved since our last visit, it was still unclear about how the service provided care and support for all people who were distressed or who may be in pain.

Visitors were generally happy with the care and support their relative received. Those who had expressed concerns previously felt that the service was improving.

We found that the care and welfare of people, particularly in relation to wound care, was still of concern at the time of our first visit for this inspection. At this time record keeping was also inconsistent and unclear. Not all staff were receiving formal support and none had completed a formal appraisal. Whilst the service had taken some steps to improve by the time of our second visit we judged that action had not been taken quickly enough to protect the care and wellbeing of people who lived at Rothsay Grange.

On other floors visitors and people who lived at Rothsay Grange said that whilst some staff were very good and caring there were times when they had concerns about the care support and treatment provided.

Some staff told us that they did not always feel that they had been well supported and that they had not always been provided with sufficient training to do their job effectively.

We found that the service needed to make improvements in a number of areas. There had been frequent changes to the management of the service and a lack of effective support to staff. People had not always experienced appropriate care, for example in relation to pressure care. People did not always feel that their concerns had been listened to. Records of care and treatment provided did not always accurately reflect the care given.

People said they had a choice of meals and were able to request different food if they wanted to. We observed that people were provided with different meals at lunchtime. Medications were managed appropriately and people said that they were given their medication at regular times. Opinion was divided about whether there were always enough staff to duty at all times to meet people's collective needs. We saw, however, that this was closely monitored by management and that bank or agency staff were generally employed to cover any identified shortfalls. Staff received good training to carry out their jobs and there were good quality assurance systems in place to monitor the service provided.

Although people who used the service were positive about the support they received, we were concerned that the service had not always followed procedures in place to protect people from allegations of abuse. The service had not consistently reported all incidents to Adult Social Services or to the Care Quality Commission. We told the provider that they needed to take action to address this.