The Grange Nursing Home

The Grange Nursing Home is registered to provide accommodation for up to 26 people with nursing care needs. At the time of inspection there were 19 older people living at the home, some of whom were living with the experience of dementia. People’s accommodation was situated on the first two floors of the home, with access provided by stairs and a lift. During our inspection the lift was not working and engineers attended to repair it. Some bedrooms had en-suite facilities, with additional bathrooms and wet rooms provided on both floors, together with a range of communal rooms for people’s use. The registered manager’s office, administrative offices, staff room and training room were located on the third floor.

The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run.

This comprehensive inspection took place on 29 March and 3 April 2018. The inspection was unannounced, which meant the staff and provider did not know we would be visiting.

At our last inspection we found that decisions made on behalf of people who lacked capacity were not always recorded in accordance with legislation. At this inspection we found the registered manager had ensured people’s ability to make decisions was assessed in accordance with the Mental Capacity Act 2005 (MCA).

At our last inspection some people described staff as kind and compassionate, whilst others told us that some staff were not as caring and considerate when supporting them to mobilise and with their personal care. At this inspection people consistently told us that staff were kind and caring.

At our last inspection people were not routinely consulted when their care plans were reviewed. At this inspection people and their families told us they had been involved in regular reviews of their care and treatment.

People experienced care that met their needs and helped them feel safe. Staff were aware of people who were at particular risk of choking, developing pressure areas or falling and how to support them safely to prevent and mitigate these risks. There was an open culture in the home where learning from mistakes, incidents and accidents was encouraged. People were kept safe because the provider thoroughly reviewed all incidents and took action to reduce the risk of a future recurrence.

The provider completed relevant pre-employment checks to ensure staff were safe to work with older people. The registered manager analysed staffing needs to ensure staff had the right mix of skills to meet people's needs safely. Staff responded to call bells quickly, which reassured people.

Medicines were managed safely and administered as prescribed, by staff who had been assessed as competent to do so.

Staff understood the importance of food safety and prepared and handled food in accordance with required standards. High standards of cleanliness and hygiene were maintained within the home.

The provider enabled staff to develop and maintain the required skills and training to meet people’s needs. People were supported to have enough to eat and drink to protect them from the risks associated with malnutrition. Where required people were supported to eat and drink safely to avoid the risk of choking.

Nursing staff ensured that people were referred promptly to appropriate healthcare professionals whenever their needs changed.

Staff understood their responsibilities in relation to the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. People were involved in making every day decisions and choices about how they wanted to live their lives and were supported by staff in the least restrictive way possible.

Staff demonstrated the provider’s key values, including kindness, respect, compassion, dignity in care and empowerment, whilst delivering people’s every day care.

The management team worked effectively with partner agencies, for example, hospital discharge planners, to ensure that people’s needs were effectively assessed before they moved into the home.

People were involved in developing their support plans, which were detailed and personalised to ensure their individual preferences were known. People were supported to complete stimulating activities of their choice, which had a positive impact on their well-being.

Where complaints highlighted areas of required learning and improvement, the registered manager had taken positive action to improve the service.

Staff took time to develop advanced care plans with people and their families, in a compassionate and sensitive manner, which ensured their wishes were respected. People were supported at the end of their life to experience a comfortable, dignified and pain-free death.

The service was well managed and well-led by the registered manager who provided clear and direct leadership, which inspired staff to provide good quality care. The safety and quality of support people received was effectively monitored and identified shortfalls were acted upon to drive continuous improvement of the service.

The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run.

There were appropriate arrangements in place for managing medicines. The registered manager was putting new stock control measures in place to enable them to check that people had received their medicines as prescribed.

Staff sought verbal consent from people before providing care and support and knew how to keep people safe in the least restrictive way. However, decisions made on behalf of people who lacked capacity were not always recorded in accordance with legislation.

We received mixed views from people about the way staff interacted with them. Some said staff treated them with consideration, whilst others said some staff could be rough when supporting them with personal care. We have made a recommendation about this.

People were involved in the initial planning and assessing of their care needs, but said they were not routinely consulted when their care plans were reviewed each month.

People received care in a personalised way. Their individual care, support and nursing needs were met at all times. Care plans provided comprehensive information to enable staff to care for people effectively. Staff responded promptly when people’s needs changed and encouraged them to make choice about every aspect of their lives.

People told us they felt safe at The Grange. Staff knew how to identify, prevent and report abuse. The registered manager conducted appropriate investigations into allegations of abuse, in liaison with other agencies.

They were enough staff deployed to meet people’s needs and people told us staff usually responded promptly to calls for assistance. Safe recruitment processes were followed to help ensure only suitable staff were employed.

Individual and environmental risks to people were managed appropriately. People were supported to take risks that helped them retain their independence and avoid unnecessary restrictions. There were plans in place to deal with foreseeable emergencies and most staff knew what action to take in the event of a fire.

People, relatives and healthcare professionals praised the quality of care delivered. Staff were skilled at meeting people’s needs in a personalised way. They were suitably trained and supported in their work by the management. They responded promptly when people’s needs changed.

People received a choice of meals to meet their dietary needs. They received appropriate support to eat when needed and were encouraged to drink often. People were able to access other healthcare services when needed and staff worked closely with specialists.

Staff knew people well and used their knowledge to design and deliver a wide range of activities to meet people’s social needs. People were supported to follow their religious and spiritual beliefs. People’s privacy was protected at all times.

The registered manager sought and acted on feedback from staff. There was an appropriate complaints policy in place and people were confident action would be taken if they raised concerns.

There was a suitable quality assurance process in place, including a range of audits and spot checks. When improvements were identified, these were actioned without delay.

There was a clear management structure in place. Staff enjoyed working at The Grange. There was an open and transparent culture where visitors were made welcome at any time. Positive links had been made with the community which benefitted people.

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.

If you wish to see the evidence that supports our summary please read the full report.

Is the service safe?

People who use the service were cared for in a safe and clean environment. Domestic staff cleaned daily and during our visit we saw people's rooms and the communal areas were clean. Equipment used had been well maintained and regular maintenance checks were performed which ensured equipment was fit for purpose. There were enough staff to meet the needs of people and the manager used the "safer guidance for nursing homes" staffing tool when planning staffing requirements. Gaps within the rota for registered nurses were filled by care workers which ensured enough staff were available and the registered manager was available to provide nursing assistance and advice as necessary.

Staff's personal records showed that the majority of staff had completed mandatory training in line with the home's policy, and staff were able to demonstrate their knowledge of safe care of people.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. No applications had needed to be submitted, however proper procedures were in place and staff were able to demonstrate knowledge of the procedures when asked.

Is the service effective?

People told us they were happy with the care they received and felt the staff met their needs. One person told us "they look after me well" and are "really excellent". The care plans we reviewed contained detailed assessments of people's needs and the people we spoke with told us they were involved with planning their care. Staff told us they "get to know residents well" which they felt enabled them to meet their needs. Staff that at the home had completed national vocational qualifications (NVQ) in support of their work. Care plans we reviewed demonstrated where care workers had high-lighted changes in people's care needs, for example: a person complained of knee pain and action had been implemented by referral to the GP services and a review plan had been put in place. This meant the care staff were effectively meeting the changing needs of people who use the service.

The manager told us about their re-enablement facilities. People requiring short term rehabilitation with a view to returning to their own home used this service. One of two re-enablement rooms were being used during our visit. The manager told us a person that had been recently admitted to this facility had been unable to return home due to a high incidence of falls. As a direct result of assessments completed at the home they had been moved to alternative nursing accommodation.

Is the service caring?

People were supported by staff who were kind and caring. We observed staff knocking on doors and asking politely when care tasks were required, which meant they cared about respecting people's privacy and dignity. People told us they were supported to do things in their own time and chose when they wanted to do things such as: activities and the time they went to bed. One person told us " I prefer to be alone" but the "staff would take me downstairs if I wanted to go". A visitor that we spoke with told us "we are a family" and felt the staff were approachable and accommodated individual needs.

We observed staff speaking with people and saw they asked " how are you?" and saw they gave people time to move freely at their own pace around the home. During mealtimes we saw they spoke kindly to people and checked they had eaten and drank enough.

Is the service responsive?

People's needs were assessed before moving to the home and reviewed on a monthly basis. Activities were provided daily and people were encouraged to take part and chose what they wanted to do. The activities coordinator told us if people wanted to change the daily activities then they were supported to do so. Visitors were encouraged at the home and staff always checked with people that they were happy for their visitors to come in.

Is the service well led?

Regular resident and staff meetings were held and people were involved in decisions about the home. During our visit we were told about a planned extension to the home and people said they were consulted about the plans during the resident's meetings. Drawings and information about the extension were displayed in the main hallway. Staff told us they felt involved in the running of the home and the manager kept them informed of any changes.

We reviewed the last residents satisfaction survey conducted in April 2014 and saw that actions had been put in place to address negative comments including signage to remind people to close doors quietly. The majority of comments were positive and people stated they were "happy" living at the home.

There were two complaints made to the manager in 2014 and people told us they had "no complaints" about the home. They said they understood the complaints process.

We found that people's nutritional needs were reviewed and that they were provided with a choice of meals. People told us they enjoyed the quality of the food.

We observed the home was clean and had effective systems in place to reduce the risk and spread of infection.

We found that staff were knowledgeable of people's specific health and personal care needs and had received training to update their skills and knowledge. Staff told us they felt supported by the provider and management team.

Relatives of people, who used the services told us they were kept informed, were listened to and given opportunity to give their view of the services provided. Comments included, 'I heard it was a nice place, and have found it is absolutely first class'.

The provider had systems for monitoring the services provided.