The Grange, Liss

About the service

The Grange, Liss is a care home, providing personal and nursing care to 14 people at the time of the inspection. The service can support up to 15 people.

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

Right Support:

People were not supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. We saw records describing incidents of restrictive practice that had not been identified as a concern and we observed staff encourage people back into communal areas when they attempted to move around the home. However, we also saw some staff supporting people to make choices, for example with their meals.

Right Care:

Care was not always person-centred and did not always promote people’s dignity, privacy and human rights. The environment was poorly maintained, dull and was not homely. We saw care was sometimes provided in line with staff needs, instead of people’s needs and preferences. Quality of care people received was inconsistent and dependant on individual staff members. We observed multiple poor and undignified interactions between people and staff. However, we also saw some kind and caring interactions.

Right Culture:

The ethos, values, attitudes, and behaviours of care staff did not always ensure people could lead confident, inclusive and empowered lives. The provider had not identified a period of particularly poor culture and atmosphere in the home that had been ongoing for many months. Staff statements from records indicated this had a negative impact on people. We saw no evidence the provider took sufficient action to address the culture in the home following this. However, the new manager demonstrated clear person-centred values and a commitment to improve the culture in the home. We also observed some very positive and caring interactions between some staff and people.

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 (28 February 2019).

Why we inspected

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 received concerns in relation to management of choking risks and robust management oversight. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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

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

We have found evidence that the provider needs to make improvements. Please see the safe 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.

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

Enforcement and Recommendations

We have made recommendations about the administration of medicines prescribed ‘when required’ and falls management.

We have identified breaches in relation to safeguarding, person-centred care, governance, the environment, dignity and respect, and notification of incidents at this inspection.

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

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 request an action plan from 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 continue to monitor information we receive about the service, which will help inform when we next inspect.

• People received person-centred care and were treated with dignity and respect.

• Staff support promoted good outcomes for people.

• The provider had a positive focus on providing meaningful activities for people.

• There was a friendly atmosphere in the service and staff were caring and compassionate in their approach towards people.

• The service met the characteristics of Good in all areas;

• Further information is in the full report.

Rating at last inspection: Last rated Good, report published 13 April 2016.

About the service: The Grange, Liss is a residential care home that was providing personal and nursing care to people living with a learning disability.

Why we inspected: This was a planned inspection based on the previous rating.

Follow up: There is no required follow up to this inspection. However, we will continue to monitor the service and will inspect the service again based on the information we receive.

The Grange, Liss provides accommodation and nursing care for up to 15 people with a learning disability. At the time of our inspection there were 15 people living in the home, 14 in the main house and one in a separate bungalow. The home has a hydrotherapy pool.

The Grange, Liss has 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 2008 and associated Regulations about how the service is run.

There were enough staff to meet the needs of people using the service. We made a recommendation in relation to the effective deployment of staff to ensure people were full engaged.

A recent staff restructuring had taken place which had resulted in improvements but further improvements were needed.

People were protected from the risks of potential abuse. Staff had received safeguarding training and were able to describe sources and signs of abuse and potential harm. They also knew how to report abuse.

Risk assessments were in place for each person on an individual basis. Clear guidance was recorded for staff in order to mitigate any identified risks. Staff acted on the guidance to protect people from the risks of potential harm.

The provider ensured staff were safely recruited to meet people’s needs by carrying out appropriate checks.

Medicines were administered safely by staff who had been trained to do so. Nurses were assessed annually in relation to their competency to administer medicines. Medicines were stored, managed, administered and disposed of safely.

Staff had received appropriate training to deliver the care and support for people living in the home. Staff had regular supervision meetings and annual appraisals and said they felt supported.

People were asked for consent before care and support was provided. Communication support plans made it clear how people communicated so that staff understood when people were consenting. Staff told us that if someone communicated ‘no’ they would respect this and offer the person support at a later time.

Where people lacked capacity to make specific decisions, the home acted in accordance with the principles of the Mental Capacity Act 2005 (MCA). For example there were mental capacity assessments and best interest decisions for one person around their decision to live at The Grange and their decision to have an influenza vaccination. Relevant DoLS applications had been submitted for people to ensure that any restrictions were proportionate and in the person's best interests.

A food tasting session was used to determine people’s likes and dislikes. Two main choices and a dessert were offered at lunchtime and a hot meal at tea time was available. People's specific dietary needs in relation to their religious beliefs and health conditions were catered for. People using the service had very specific requirements in terms of the consistency of the food they required. The chef had records of these in the kitchen which matched with the requirements recorded in people’s support plans and with the type of food we observed them to eat. People were supported to have enough to eat and maintain a balanced diet.

Health professionals were appropriately involved in people’s care. People had complex conditions and needed support from a variety of health professionals. Each person had a health action plan which recorded the support required and the outcomes of any visits.

Staff were supportive and caring. The registered manager in particular was observed to interact in a positive way with people, acutely aware of people’s individual needs she approached them in individual ways which people clearly loved and responded to. Other staff were observed to respond individually to people, for example by cheering people up when they were in a bad mood.

People’s rooms were decorated in a personalised way. These included cushions with photographs of family members on them, photographs which were important to people, cuddly toys, flowers and butterflies. People were supported to maintain close relationships with their family and friends.

Due to their complex needs people were not able to actively participate in their support plan. The level of involvement in support plans was recorded in people’s individual plans and was mostly in relation to observing the person and their reactions.

Staff explained how they respected people’s dignity by knocking on their bedroom doors before entering. Staff treated people in a dignified and respectful way and addressed them with their preferred names. People were spoken to and about with affection. Everyone was dressed respectfully with freshly laundered clothes which were matching. People were supported to be as independent as possible.

Support plans were included a range of documents to describe people's needs. There were personalised, up to date and aligned with best practice. Support plans provided guidance for staff on what was important 'to' and important 'for' the person and included people's decision making and communication needs.

People took part in a variety of activities and photographs of these activities were displayed throughout the home. Activities included swimming, sailing, going on a train, going to a music festival and the Goodwood festival of speed. People also took regular holidays which included taking part in a variety of activities. Everyone had their own activities plan which was in easy read format so that people knew what they were doing and could look forward to their activities.

The provider listened and responded to feedback about people’s experiences, concerns and complaints. The complaints book included only one formal written complaint which had been appropriately dealt with in a timely manner by the registered manager. Relatives told us they found the registered manager approachable and responsive to their concerns. Feedback was sought from staff, relatives and people and appropriately responded to.

There was an open and transparent culture within the home. Staff were able to raise any issues or concerns with the manager who, they told us, always listened and responded. Relatives told us they had a good relationship with the registered manager whom they respected. They were positive about her leadership of the home.

Staff told us they were aware of their roles and responsibilities, as these had been discussed in a recent team meeting, following the recent staff restructuring. New roles had been developed in order to encourage staff to take ownership of the development of the home and the service.

The registered manager submitted relevant notifications to the Care Quality Commission (CQC) in a timely way. A notification is an important event which the provider is required to tell us about.

The registered manager was aware of the provider’s vision and values, which included, passion for care and positive energy. She felt these values were reflected through the passion of her staff to make a positive difference in people’s lives.

Checks were undertaken to ensure the quality of the service and quarterly and annual audits took place to drive through improvements.

As part of this inspection one of the thirteen people who were using the service on the day of our inspection was able to share with us some of their experiences of living at The Grange. We also spoke with three people's relatives, the registered manager, the operations manager and three care staff. We reviewed records relating to the management of the home which included, four care plans and daily care records.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

Is the service safe?

People were safeguarded against the risk of abuse as staff had received training and had access to relevant guidance. People's relatives we spoke with felt that their relatives were safe in the care of the service. One person's relative told us 'Staff are good at safeguarding.'

We saw that where people had been restrained with the use of a lap belt on their wheelchair for their safety, the correct legal process had been followed. This ensured that people had only been subjected to a proportionate level of restraint in relation to the risk of them falling out of their wheelchair and that the decision to use a lap belt had been made in their best interest.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLs) which applies to care homes. The registered manager was aware of recent case law and had started to consider which people this might impact upon. They had identified the relevant supervisory bodies to inform regarding applications that may need to be completed.

There was evidence that staff had undergone appropriate checks on their suitability as part of the recruitment process. The professional registration of nurses had been checked. People's relatives we spoke with told us that they had 'No concerns about the staff.'

Is the service effective?

People's relatives told us that people received good care that met their needs. One relative said 'Staff understand X' and 'Staff look after X well and meet X's needs'.

Staff had an understanding of people's communication needs. They ensured that the service was delivered in a way that enabled people to make choices for themselves where possible. We spoke with people's relatives who told us 'They involve X in choices' and another said 'Staff promote choice where possible. They make the effort to involve X.'

The provider had an understanding of people's diverse needs and they had ensured that the service was able to meet the needs of people who use a wheelchair. Where people had health needs these had been identified using relevant tools. People had care plans in place to meet their identified needs.

Is the service caring?

We saw that staff were caring towards people. They treated them with dignity and respect when they provided their care. We spoke with people's relatives who told us 'Staff are very caring' and 'The manager is caring.'

People were relaxed in the company of staff and staff spent time with them. Care was provided at an unrushed pace that met people's needs. Staff were seen to be familiar with people's routines and preferences.

Is the service responsive?

People's relatives told us 'Staff responded well to changes in X's needs'. We saw evidence that the service had processes in place to monitor people's welfare and that they had responded promptly to changes in people's needs.

The service had ensured that relevant professionals had been contacted when there had been changes to people's needs. If people had to stay overnight in hospital then they had been supported by staff from the service.

Is the service well-led?

People's relatives expressed the view that the service was well led. One relative told us 'X is a good manager.' Staff also told us that they felt that they were well led.

People's views had been sought regularly through meetings. There was an annual survey that was circulated to people, their relatives and staff. One person's relative told us 'I have received an annual survey.'

There were systems in place to monitor the quality of the service provided. We saw evidence of both internal and external audits that had been completed.