Grange Nursing Home

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

Risk was assessed, and plans put in place to guide staff on how to safely manage areas of risk. However, records used to monitor risk were not always completed to show people had received the safe care they needed.

The systems for monitoring the quality and safety of the service were not always used effectively. They failed to identify and mitigate risk and bring about improvements.

It was observed during the inspection that people were comfortable and happy in the presence of staff who interacted with then in a caring and patient manner.

Systems and processes were in place to safeguard people from the risk of abuse and family members told us they felt their relatives were safe with staff. GPs and other healthcare professionals were contacted for advice about people’s health needs whenever it was identified as necessary.

Medicines where managed safely. Infection control standards were also monitored and managed appropriately. Accidents and incidents were recorded and reviewed in order to minimise the risk of reoccurrence.

Staff were recruited safely and there appeared enough staff available to meet people's day to day needs. Feedback from people and their relatives indicated that there were familiar staff on duty including the use of agency staff.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update The last rating for this service was requires improvement (07 August 2019). The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections. At this inspection we found the provider was in breach of regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Why we inspected

This inspection was prompted by a review of the information we held about this service. We also received concerns in relation to people’s nursing care needs. As a result, we undertook a focused inspection to review the key questions of Safe and Well-led only.

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.

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

We have found evidence that the provider needs to make improvements in regard to governance and reporting. However, the provider has taken prompt action to mitigate the risks.

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

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.

Grange Nursing Home is providing personal and nursing care to 17 people aged 65 and over at the time of the inspection. The service can support up to 32 people.

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

People and their relatives told us that there had been an improvement in the home since the new manager had been in post.

We observed care being delivered within the home and saw that people were comfortable in the presence of staff, positive relationships had developed between people receiving support and care staff. People told us staff were kind and treated them with dignity and respect.

People had up to date risk assessments and care plans in place that identified their needs. Improvements had been made to the management of the health and safety issues such as fire safety, water and building management.

Medicines were managed safely and the manager had worked closely with the medicines management team from the local authority to make improvements.

Staff were recruited safely and received regular training and supervisions. Checks were made on their performance to ensure competence and confident in their roles. Staff, attended staff meetings to keep up to date and to share their views.

Incident and accidents were analysed for patterns and trends. Risks to people were assessed safely and referrals were made to other professionals in a timely manner where advice was required.

People received the support they needed to eat and drink and maintain a healthy and balanced diet. People told us they enjoyed the food available to them and were able to choose alternative meals if they did not like what was on the menu.

People were now able to access enjoyable and fulfilling activities.

The registered provider and manager had developed and implemented a robust quality assurance process that drove improvement in the home and was constantly being reviewed.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update:

The last rating for this service was Inadequate (published 06 March 2019) and there were multiple breaches of regulation. 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. However, these improvements had happened over a short period of time. This needs to be sustained by the registered provider and manager.

This service has been in Special Measures since 06 March 2019. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This was a planned inspection based on the previous rating.

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

The overall rating for the service has changed from Inadequate to Requires Improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Grange Nursing Home 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.

Grange Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Grange Nursing Home accommodates 32 people in one building and provides care including those requiring nursing care. At the time of inspection there were 19 people living in the home. There are 19 single bedrooms and 5 double bedrooms over two floors, with another 2 single rooms on a mezzanine floor. There are also 3 lounge/dining rooms. A passenger lift is provided for people to move between floors, but the 2 bedrooms on the mezzanine floor are only accessible by a stair lift.

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 the time of inspection, the previous manager was in the process of de-registering and the home manager was in the process of registering. The home had no deputy manager in place.

During our inspection, we identified five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulated Activities 2014 in respect of Regulation 9 person centred care; 11 consent, 12 safe care and treatment; 17 good governance and 18 staffing, of the Health and Social Care Act 2014 Regulations. You can see what action we told the provider to take at the back of the full version of the report.

We found that the Mental Capacity Act 2005 and the Deprivation of Liberty (DoLS) 2009 legislation had not been adhered to in the home. We saw that people’s mental capacity to make decisions had not always been assessed appropriately, consent had not always been sought and best interest meetings had not taken place when appropriate.

Accidents, incidents and complaints had not been managed appropriately. Audits of the service were ineffective and in some cases not carried out. There was no evidence that external audits had been actioned.

We saw no evidence of a robust induction process into Grange Nursing Home for either permanent or agency staff. Staff had not attended training the provider required them to and there was no oversight of training or induction by the manager or provider.

Care plans and risk assessments had not been updated accurately and in some cases contained contradictory guidance that if followed would pose a risk to people's health and safety. People’s personal emergency evacuation plans did not match their risk assessments.

There were no activities available for people in the home and during the inspection we observed that staff did not always have the time to interact with people. People were not asked what they wanted to watch on the television and we identified staff did not always listen to what people were saying.

People we spoke with, relatives and staff all indicated there were issues regarding staffing levels. We saw that there was a high use of agency staff and that this impacted on the quality of the care being delivered.

Overall, we found the management of the home inadequate.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location from the providers registration.

During this inspection we found that improvements had been made however there were still concerns with the service regarding maintenance of premises and equipment, staff induction, supervision and appraisal. During this inspection, we identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulated Activities 2014 in respect of Regulation 15 premises and equipment and Regulation18 Staffing. You can see what action we told the provider to take at the back of the full version of the report.

Grange Nursing Home provides care for up to 32 people, including those requiring nursing care. There are 19 single bedrooms and five double bedrooms over two floors, with another two single rooms on a split level floor. There are also two lounge/dining rooms. A passenger lift is provided for people to move between floors, but the two bedrooms on the split level floor are only accessible by a stair lift. The home has its own gardens and a car park. At the time of inspection 24 people were living at the home.

Grange Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The home had a manager who been registered with the Commission since December 2017. However the deputy manager and not the registered manager was in attendance during the inspection.

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.

For the most part, appropriate recruitment processes and checks had been made before new staff started working at the home. However, their previous employment history had not always been completed on their application forms. Records did not show that new staff completed an induction programme at the beginning of their employment and there was little evidence of regular supervision and appraisal.

Care plans were in place for each person however not all risks to people's safety and well-being had always been fully assessed. Evidence of health and safety checks that should be carried out on equipment and premises was not always available. This was in regard to the passenger lift and lifting equipment. We also identified an issue with water temperatures that had not been acted on.

Manager and provider audits were not always effective and so did not drive improvement in the home.

People we spoke with said there was not enough going on with regard to social activities but that the food was good and nutritious with a good choice of meals.

People told us they felt safe at the home and they had no worries or concerns. Relatives and friends also told us they felt people were safe. The staff at the home knew the people they were supporting and the care they needed. We observed staff to be kind and respectful towards people.

We found that the Mental Capacity Act 2005 and the Deprivation of Liberty (DoLS) 2009 legislation had been adhered to in the home. The provider told us the majority of people at the home lacked capacity to make all of their own decisions and that a number of Deprivation of Liberty Safeguard (DoLS) applications had been submitted to the Local Authority.

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 the time of inspection the service had a manager in post who was going through the registration process with Care Quality Commission but was not yet registered.

We found a breachof Regulation 12 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 the full version of this report.

We observed unsafe moving and handling practices and found staff were using moving and handling techniques that were not in accordance with people’s identified risk assessments and risk management plans. This placed people and staff at risk of physical harm.

We also found some concerns with maintenance issues in the home.

We found that the Mental Capacity Act 2005 and the Deprivation of Liberty (DoLS) 2009 legislation had been adhered to in the home. The registered manager told some people at the home lacked capacity to keep themselves safe outside of the home and that the appropriate Deprivation of Liberty Safeguard (DoLS) applications had been submitted to the Local Authority.

People who lived at the home were able to tell us who the manager was and said they felt comfortable if they felt the need to complain. We saw that the manager was a visible presence in and about the home and it was obvious that they knew the people who lived in the home well.

The service had systems in place to ensure that people were protected from the risk of harm or abuse. We saw there were policies and procedures in place to guide staff in relation to safeguarding adults.

Staff had been recruited safely with appropriate criminal records checks and the registered nurses had appropriate PIN checks and were able to work safely.

We observed a medication round and saw that the way medication was administered was safe. Records relating to people’s medicines matched what had been administered. Medicines were stored safely and there was evidence that staff administering all types of medication were trained and competent to do so.

We saw that since the manager had been appointed there had been significant improvements in the service including auditing processes and environment.

The home was clean, safe and well maintained. We saw that the provider had an infection control policy in place to minimise the spread of infection and a good supply of personal and protective equipment. For example, hand gels, disposable aprons and gloves.

People had access to sufficient quantities of nutritious food and drink throughout the day and were given suitable menu choices at each mealtime, these options had been chosen by the people who lived at Grange Nursing Home.

The staff in the home knew the people they were supporting and the care they needed. We observed staff to be kind and respectful and the home supported the people to access a range of activities, this promoted their independence and well-being.

Care plans provided sufficient information on people's needs and risks and guidance to staff on how to meet them. Regular reviews of care plans took place to monitor any changes to the support people required.

The two bathrooms downstairs are currently out of commission and the people living on the ground floor have to access the first floor that has a wet room, a shower room and one other bathroom available.

There is currently a temporary manager in post as there was no permanent manager employed at the time of inspection. The provider was taking steps to address this.

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.

We spoke with a senior member of staff for the home as the temporary manager was unavailable at the time of the inspection.

The majority of people we spoke with told us they felt safe at the home. They had no worries or concerns. People’s relatives and friends also told us they felt people were safe. During our visit, however we identified concerns with the service.

We found breaches in relation to Regulation 15 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 the full version of this report.

We found that some health and safety and maintenance requirements were not being carried out and that the organisation had not notified the commission of safeguarding incidents.

We found that the Mental Capacity Act 2005 and the Deprivation of Liberty (DoLS) 2009 legislation had been adhered to in the home. The provider told us the majority of people at the home lacked capacity and that a number of Deprivation of Liberty Safeguard (DoLS) applications had been submitted to the Local Authority in relation to people’s care. We also saw that that the majority of staff had undertaken mental capacity training, although some staff did not have a working knowledge of the Act.

People had access to sufficient quantities of nutritious food and drink throughout the day and were given suitable menu choices at each mealtime. All medication records were legibly and properly completed. All staff giving out medication had been medication trained.

We reviewed six care plans, these provided sufficient information on people’s needs and risks and guidance to staff on how to meet them. Regular reviews of care plans took place to monitor any changes to the support people required.

We saw that some of the communal areas in the home looked tired and shabby and would benefit from re-decoration and we noted some uneven surfaces at the front of the building and in the car park area which could prove difficult for people who had mobility problems when accessing this area.

People said that staff maintained their privacy and dignity when carrying out personal care, and that they felt safe in the home. One person said of the staff "I can't fault them".

People who used the service felt they were well cared for. They told us:

"It's very good here",

"Anything you want, they'll do for you"',

"They look after me ok"'

"I'm reasonably comfortable here".

People we spoke with had no complaints about the food and knew there were choices available. One person told us "The food is very good and you get plenty of options". Another said "The food's alright, they come and ask you what you'd like".

We noted the home was clean and generally well maintained. People were able to decorate their rooms individually and bring personal possessions to the home.

Appropriate checks were undertaken before staff began work.