Archived: The Grange

At our last inspection in June 2017, we found one continuing breach of the Health and Social Care Act 2008. This related to good governance. We rated the service as requires improvement and issued a warning notice. Some of the concerns and shortfalls related to the homecare service which was registered together with the care home service. In January 2018, the provider registered the homecare service separately.

At this inspection, we found that improvements had been made and the provider was no longer in breach of the regulations.

The previous registered manager was now the operations manager and oversaw the management of the Grange and the provider’s other two services. The manager designate [in waiting] at our last inspection was now 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 and associated Regulations about how the service is run.

An effective system was now in place to ensure the safety of the premises and equipment. Key pads and a sensor had been fitted to the main staircase to reduce the risk of falls on the stairs. The home was clean and there were no malodours in any of the areas we visited. A new washer disinfector had been installed for the cleaning of continence equipment. People's individual needs were met by the adaptation, design and decoration of premises. The home had been a vicarage and had a homely feel.

Medicines were managed safely. The home had limited storage areas. The registered manager’s office was used to store medicines. Staff made the best of the facilities available. Medicines were safely locked away in a trolley and lockable cabinets.

Staff assessed the risks relating to people to safeguard their health, safety and welfare. Accidents and incidents were analysed to help identify any trends to ensure action was taken to reduce any reoccurrence. There were enough staff deployed to meet people’s needs. Safe recruitment procedures were followed.

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.

Staff received appropriate training to meet people’s needs. There was a supervision and appraisal system was in place to make sure staff were supported.

People’s nutritional and hydration needs were met. There was an emphasis on home baking and fresh produce was purchased from local suppliers to help support the local community.

People and relatives told us that staff were caring. Staff displayed warmth when interacting with people. Person centred care plans were in place which helped staff deliver care which met people’s personal preferences.

Two activities coordinators were employed to help meet people’s social needs. A varied activities programme was in place.

There was a complaints procedure in place. There was one ongoing complaint which had been sent to the local authority and not to the home directly. The complaint was being independently investigated on behalf of the local authority. None of the people and relatives with whom we spoke raised any complaints.

An effective system was now in place to monitor the quality and safety of the service. People and relatives were complimentary about the home. One relative said, “It’s a community there.” People, relatives and staff were involved in the running of the service. Meetings and surveys were carried out.

Staff told us they enjoyed working at the home. We observed that this positivity was reflected in the care and support which staff provided throughout the day.

At our last inspection on 10 February 2016, we found two breaches of the Health and Social Care Act 2008. These related to safe care and treatment and good governance. We rated the service as requires improvement. At this inspection we identified a continued breach with regards to good governance.

We have written our report under the headings Care Home and Homecare to ensure that our specific findings for both services are clear.

Care Home

The care home is located in Rennington village close to the town of Alnwick and is registered to provide accommodation for up to 27 people, some of whom have a dementia related condition. There were 25 people using the service at the time of the inspection. The Grange also provides a day care service. We did not inspect this part of the service because it was outside of the scope of our regulations.

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 registered manager told us that a manager designate [manager in waiting] was going to register with CQC and become the new registered manager. She would then concentrate on her role as operational manager and oversee the care home, home care service and the provider’s other care home which was located nearby. One of the senior care workers had been appointed as the new deputy manager.

We identified shortfalls and omissions with the recording and management of medicines. We noted that interview records were not in place to demonstrate how the provider had assessed the suitability of staff to work at the service in line with their procedure.

We found that an effective system was not fully in place to ensure the safety of the premises and equipment and assess the risks relating to people to safeguard their health, safety and welfare.

There were sufficient staff deployed to meet people’s needs. We saw that staff carried out their duties in a calm, unhurried manner and had time to provide emotional support to people.

There were safeguarding policies and procedures in place. Staff were knowledgeable about what action they would take if abuse was suspected. The local authority told us there were no organisational safeguarding concerns with the service. People told us they felt safe.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that as far as possible people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. We found an effective system was not fully in place to make sure the service met their legal requirements in line with the Mental Capacity Act 2005.

Staff told that there was sufficient training. The home’s training policy stated that staff covered the Care Certificate standards as part of their induction programme. It was not clear however, that staff whose personnel files we checked had undertaken the Care Certificate. The Care Certificate is a set of nationally recognised standards to be covered as part of induction training of care workers.

People told us they received a suitable diet. We found however, that an effective system was not fully in place to make sure that records relating to people’s dietary needs were accurate.

We observed positive interactions between people and staff. An activities coordinator was employed to help meet the social needs of people. A varied activities programme was in place.

A complaints procedure was available. Feedback systems were in place to obtain people and their representatives’ views.

We spoke with the registered manager about the omissions mentioned above. She took immediate action to address the concerns we raised. Whilst we were satisfied that action had been taken; this had only been instigated after we had highlighted the shortfalls. We considered that an effective system was not fully in place to assess, monitor and mitigate the risks relating to the health, safety and welfare of people and ensure that accurate and complete records relating to people, staff and the management of the service were maintained.

Homecare

The service provided personal care to 20 people living in the North Northumberland area.

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.

We identified shortfalls and omissions with the recording and management of medicines.

Three of the four people we visited did not have a care plan in place and two people had no risk assessments. This meant there was limited evidence that people’s needs had been assessed and action taken to minimise any risks. There was no information about people’s likes and dislikes or evidence that people had been involved or consented to their care.

Audits and reviews had been completed for three of the four people we visited. However, these had not highlighted that there were no care plans or risk assessments in place.

Despite our findings and identified shortfalls; people and relatives were very positive about the service.

We identified one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This relates to good governance.

Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

We have written our report under the headings Homecare and Care Home to ensure that our specific findings for both services are clear. The Grange also provides day care but we did not inspect this as it was outside of the scope of our regulations.

Homecare service.

The Home care service supported 28 people who lived in their own homes in Northumberland. This equated to 400 hours of care a week.

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 registered manager and senior care coordinator assisted us with our inspection.

We checked the management of medicines and found that there were no lists of medicines with the dosette box from which medicines were administered. Instructions about what should be administered were unclear.

Safeguarding procedures were in place and staff were knowledgeable about what to do if abuse was suspected.

Risk assessments had been carried out which documented action staff should take to minimise risks.

Staff were unhurried and calm while delivering care and care home staff were able to provide support in the event of sickness or unexpected absence.

There were no capacity assessments completed for people using the homecare service or best interests decisions recorded in relation to using specific pieces of equipment. A new consent to treatment policy had been developed and progress had been made towards improving practice in the care home, but this was inconsistent between the two services. We have made a recommendation about this.

Staff received regular supervision and appraisals in both services. Staff told us they felt well supported. Records of induction did not record competency assessments in aspects of care delivered by the homecare service and this was passed to the manager who said they would address this.

Staff training had been provided but there were gaps in training records and staff had not completed training in the Mental Capacity Act 2005. One staff member had not completed any training for a year and this had not been addressed through the manager’s performance management system.

People and relatives were complimentary about the care provided by staff. We saw that they spoke kindly and courteously with people in both services and a number of cards and letters commented upon the kindness and care shown by staff.

Audits of medicines management and care plans had not been carried out and. The manager advised that the audits had been delayed due to the increase in workload following the rapid expansion of the homecare service.

We judged that there was insufficient management time devoted to the homecare service, however a manager had been appointed in the care home to support the planned reorganisation of the management of both services.

Care home service.

The service was located in Rennington village close to the town of Alnwick and was registered for 26 people and there were 24 people using the service at the time of the inspection, some of whom were living with dementia. We were supported during the inspection by the registered manager and deputy 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 and associated Regulations about how the service is run. The registered manager and senior care coordinator assisted us with our inspection.

We checked systems for the safe ordering, receipt and return or disposal of medicines. We found that medicines were not always stored safely as staff were routinely leaving the keys in the lock of the medicine cupboard.

The safety of the premises and equipment were routinely checked and emergency contingency plans were in place to ensure the continuity of the service during inclement weather for example. One safety certificate was unavailable at the time of the inspection.

Recruitment procedures included obtaining references and applicants were checked by the Vetting and Barring Service (DBS). The DBS checks the criminal record of applicants and whether they have been barred from caring for vulnerable adults. This helped to protect people using the service from abuse.

The home was clean and systems were in place for the control and prevention and spread of infection. Staff were knowledgeable about the procedures to follow.

A record of accidents and incidents was maintained which were analysed by the manager. Equipment was provided to reduce the risk of accidents for example falls sensor mats which alerted staff to the movement of people prone to falling.

There were adequate numbers of staff on duty during the inspection and relatives told us that staff had time to care.

Staff records checked confirmed staff had received regular training and plans were in place to provide staff training in the Mental Capacity Act 2005 (MCA). A new consent to treatment policy had been developed and care records contained improved documentation to support staff to work within the principles of the MCA.

Nutritional needs were supported and people had access to professional advice and specialist diets where required.

Bedrooms we saw were individualised and homely. Some areas of the home were in need of redecoration and refurbishment and we saw that plans were in place to complete this. There was a lack of storage which had been identified by the provider and there were plans in place to provide additional storage outside the building. We observed an item of equipment being stored inappropriately. This was addressed immediately and plans were in progress to provide additional suitable storage. A planning application was in place to extend the building.

Staff were polite and courteous and responded with humour and sensitivity to people. They were quick to respond when people appeared worried or anxious. The privacy and dignity of people was maintained.

A registered manager was in post and was supported by a deputy manager. A new manager had been appointed as there were plans to strengthen the management of the service by appointing the registered manager into a senior operational management role within the organisation.

Staff and relatives told us they felt well supported by the manager and that morale was good in the home.

Systems were in place to seek the views of people relatives and other stakeholders including meetings and surveys.

We found two breaches of the health and Social care Act 2008 (Regulated Activities) Regulations 2014. These related to safe care and treatment and good governance.

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

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well-led?

Below is a summary of what we found.

Is the service safe?

We found the provider had in place effective systems to identify, assess and manage risks to the health, safety and welfare of people using the service and others. We saw people's care was assessed and care plans were in place that included appropriate risk assessments.

We looked at the records and saw where necessary a referral for a mental capacity assessment and best interest's decision was made, where required, for people who were unable to make decisions. Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) is law that protects people who are unable to make decisions for themselves. The manager had a good understanding of the MCA and DoLS and was able to describe the process followed when a DoLS was applied for a person who used the service.

There were effective systems in place for the safe administration and management of people's medicines. Records were up to date and corresponded with the stock of medicines held.

We saw the recruitment process was robust and staff records included evidence of appropriate references and Disclosure and Barring (DBS) checks. This was to ensure staff were safe to work with people at the Grange and in their own homes.

Is the service effective?

People's health and care needs were assessed with them and they were involved in this process. We saw that particular care needs were identified in individual plans for example, dietary needs or dementia care.

Staff training is provided that takes account of the needs of the people in the home. For example, we saw training in dementia and administration of medicines had been provided.

Is the service caring?

We saw staff responded kindly and promptly to people. Care workers were patient and encouraging to people as they assisted them. One person told us, 'It's a really good place to live and I like the staff. They are very kind.' A person who had care provided in their own home said, 'I get a good service and I always know who is coming to support me. The staff are all very good. I am happy with the service.' A relative told us, 'X is really well cared for and the staff are marvellous.'

People's preferences, interests, aspirations and diverse needs were recorded and we saw staff were aware of these during the inspection. We noted people's privacy was respected and people were afforded choices about where and how they spent their time.

Is the service responsive?

We saw evidence that the care staff identified changes in people's needs and acted to make sure they received the care they needed. For example, there was evidence that care plans had been amended when a person returned from hospital and when someone had lost weight.

People told us they were aware of the complaints procedure and were satisfied staff would respond to any concerns. Staff could describe how they would assist a person to make a complaint. We saw there were systems in place for dealing with and recording complaints.

We saw there was an activity programme planned each week. People told us they enjoyed the activities, particularly the music and the exercise class. People's records identified particular interests or hobbies and we saw these were reflected in the programme.

We saw records of meetings for people who used the service. There was evidence people had opportunities to put forward their views about the service and had identified improvements in the gardens to suit their needs. People told us they were satisfied staff listened to and acted upon their views.

Is the service well led?

The staff we spoke to were all aware of the complaints, safeguarding and whistle blowing procedures. All of the staff we spoke with were able to describe the appropriate procedures to be followed in the event of someone raising an issue with them.

The service had a quality assurance system in place that included the use of surveys from people who used the service. This meant people were able to feed back on their experience and the service was able to learn from this. Audits of care records, medicines, health and safety, infection control and premises were carried out monthly and any shortfalls in the service were acted upon promptly.

Staff had regular supervision, appraisals and staff meetings which meant they were able to feedback to the management of the home their views and suggestions. Staff we spoke with confirmed their views were listened and account was taken of them. They said they felt well supported by the management of the home.

We found people's needs were assessed and care was planned in line with their needs. One relative told us, 'I am happy with the care my relative receives. She has a lovely room and the staff provide wonderful care.' Care plans were regularly updated and contained clear information about individuals' care.

We saw people were supported to eat and drink sufficient amounts to meet their needs. One person said, 'I really enjoy my meals and all the food is wonderful." Another person said, "I like the home baking best.'

The home was clean and staff had received training in infection control. People told us the home was always clean and there were never any odours.

At the time of this visit there were enough qualified, skilled and experienced staff available to meet people's needs. We saw staff responded promptly to requests for assistance.

People's personal records were accurate, fit for purpose and held securely. Staff records were kept in an appropriate format.

We saw relationships between staff and people were good and there was a relaxed atmosphere. People told us staff spoke to them respectfully and they were consulted about their care preferences. We saw good interactions between staff and people during our visit.

People told us they felt satisfied staff helped them to manage their medicines. People were protected from the risk of associated with medicines because medicines were safely administered.

Staff recruitment procedures were followed and appropriate checks were undertaken before staff began work.

There were effective complaint procedures in place and people were aware of how to make a complaint. People were satisfied staff listened to their views.