Aaron Grange is a residential care home for 68 older people, many living with dementia. The home is split into two separate units; Beecham suite and Emily suite. People with dementia stay mainly in Emily suite. Accommodation includes mainly single bedrooms with ensuite facilities. There is a large enclosed garden area and separate seating area for people to enjoy. A passenger lift provided access to the upper floors. At the time of our inspection 58 people were living at the home.

At our last inspection we rated the service good. At this inspection we found the evidence continued to support the rating of good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

Everyone who lived in the home said they felt safe. There were robust measures in place to ensure people were safe. Risk assessments were in place for areas such as pressure care, safe environment, falls and mobility, and nutrition and hydration.

There were sufficient staff on duty to meet people's needs. The manager completed a dependency tool for each person each week which provided this reassurance. Staff rotas showed a consistent number of staff were on duty each day. People told us call bells were answered within a reasonable time.

Staff had been appropriately recruited to ensure they were suitable to work with vulnerable adults. We found that staff had the skills, knowledge and experience to support people effectively and safely.

Staff were supported by the manager through regular supervisions, annual appraisal and regular training. Staff had attended training in subjects such as first aid, fire safety, food safety, safeguarding and medication. New staff were required to complete an induction. Staff meetings were held regularly.

Medicines were managed safely and people received their medicines as prescribed. Staff had been trained to administer medicines to ensure errors were kept to a minimum.

The home was very clean and there were no odours. The home was well maintained and in good decorative order. People's bedrooms were personalised and were decorated and furnished to a high standard.

Regular checks and tests, such as gas, electricity, water safety, fire drills, fire alarm tests and external checks of firefighting equipment, were completed to maintain safety in the home.

People's needs were assessed and reviewed regularly to reflect their current health and support needs. People were supported to maintain healthy lives; records showed that people were supported to attend medical appointments.

People were supported to eat and drink enough to maintain a balanced diet and meet their dietary requirements. Drinks were offered at various times throughout the day to ensure people’s hydration needs were met. Staff understood people’s individual nutrition and hydration needs and we saw that meals were provided accordingly. However, people gave us mixed responses with regard to their liking of the food.

Everyone living in the home was very complementary about the attitude of the staff and the way they were treated. We observed staff speaking to people respectfully; they were extremely patient and approached people with a smile. Staff were tactile with people and offered physical contact for reassurance,

Staff knew people and understood their different communication needs. Staff supported people to make decisions about their care, support and treatment as far as possible. Records showed people's preferred routines, likes and dislikes.

People and their family members were invited to attend six monthly care reviews. This ensured they were involved in the planning of their care and family members kept up to date with matters relating to their relative’s health and welfare.

People we spoke with told us they could “please themselves about their da

This was an unannounced inspection, carried out on 01 September 2015.

Aaron Grange is registered to provide care for up to 68 people who require personal care. The service is situated in the Huyton area of Knowsley, not far from local amenities such as shops, buses and trains.

The service has had a registered manager since September 2014. 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.

The last inspection of Aaron Grange was carried out in September 2014 and we found that the service was not meeting all of the regulations we assessed. The registered provider sent us an action plan outlining how and when they intended to meet the regulations. During this inspection we found that the required improvements had been made within the timescale set by the registered provider.

Improvements had been made to ensure allegations of abuse were reported and investigated in line with the registered providers and the local authorities safeguarding procedures. People who used the service felt safe. Staff knew about the systems in place to protect people from the risk of harm and they knew how to recognise and respond to abuse correctly.

Improvements had been made to ensure staff were recruited safely. Prior to starting work at the service applicants were required to complete an application form providing details of their qualifications, experience and employment history. Staff did not commence work until a satisfactory Disclosure and Barring scheme (DBS) check was carried out and two references were obtained, including one from the applicant’s most recent employer.

Improvements had been made to ensure people were treated with dignity and respect. People were made comfortable when they got out of bed each morning and they were offered a hot drink before being served breakfast. Staff were gentle and kind in their approach and they spent time chatting with people about things they enjoyed. Staff addressed people in a respectful manner and treated people as individuals.

Improvements had been made to ensure there was an effective system in place to identify, assess and manage risks to the health, safety and welfare of people. A range of checks were regularly carried out across the service. These included checks on care plans, staff records and other records to ensure procedures were appropriately followed. The service was well managed by a person who people, staff and family members described as supportive and approachable.

The CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) and to report on what we find. We saw that there were policies and procedures in relation to the Mental Capacity Act 2005 (MCA) and DoLS to ensure that people who could not make decisions for themselves were protected. Some people who used the service did not have the ability to make decisions about aspects of their care and support. Family members had consented on behalf of their relative although they did not have legal authority to do so. Therefore the legal requirements outlined in the MCA had not always been followed where people lacked the capacity to make decisions.

The lunch time meal for some people was unsupportive and disruptive. Staff did not provide people with the support they needed with their meal and they cleaned up around people whilst they were sat at the dining table. People told us they had enough to eat and drink and that they had access to drinks and snacks in between main meals. People’s nutritional needs were planned for and people who were at risk of poor nourishment had their food and fluid intake closely monitored. People had been appropriately referred onto dieticians and nutritionists and their advice and guidance was taken note of.

People told us they received their medicines on time. Medicines were kept securely and handled by authorised staff who had undertaken training relevant to the management of medications. Records were maintained for all medicines received into the service, medicines destroyed and those returned to the pharmacist who supplied them. The records were signed by only one member of staff as opposed to two, which would reduce the risk of errors occurring.

People had their needs met and they were supported by the right amount of suitably skilled and experienced staff. Staff received training and supervision relevant to their role and responsibilities. Supervision sessions provided staff with an opportunity to discuss their work and any future training and development needs.

People’s care and support needs were up to date and reviewed on a regular basis with the person or other appropriate people. People told us that the staff knew them well and provided them with the right care and support.

People who used the service and relevant others were provided with information about how to complain and they told us they would not be worried about complaining if they needed to. People were confident that their complaints would be listened to and acted upon. A record of complaints was maintained and this showed people’s complaints had been acknowledged and dealt with in a timely way.

We carried out an inspection on 04 June 2013 and published a report setting out our judgement. We asked the provider to send us a report of the changes they would make to comply with the standard they were not meeting.

We have followed up to make sure that the necessary changes have been made and found the provider is now meeting the standard included within this report. This report should be read in conjunction with the full inspection report.

We visited Aaron Grange as part of this review. We reviewed records and spoke to staff. This confirmed that they were now meeting the standards.

We also spoke met with the Knowsley safeguarding team regarding the service. No issues of concern were raised.

Prior to this inspection we were notified of concerning information in respect of consent and care and welfare of people who used the service.

During our visit we spoke with people who used the service, relatives and staff. We looked at the care records for people who used the service to see how their needs should be met. We looked at infection control audits, staff rotas and information on complaints.

We observed good rapport and interaction between the people who used the service and staff. From observation and information reviewed it seemed that people were happy with the care and support provided.

Some people who used the service had complex needs and required dementia care. They were not able to verbally communicate their views and experiences to us. Due to this we have used a formal way to observe people in this review to help us understand how their needs were supported. We call this the ‘Short Observational Framework for Inspection (SOFI).

We found the home to be clean and regular checks had been carried out to ensure the required standards of cleanliness and infection control.

We found that there were sufficient staff on duty to provide people with the care and support they needed. Relatives and people who used the service told us that the staffing level were satisfactory.

We noted that although people who used the service were asked about their choices and preferences, consent was not consistently recorded in their care records.

We also asked the local authority and service commissioners for their view about the service and they did not raise any concerns.

We spoke to 11 visitors and five people who used the service. People who used the service and the visitors told us they liked the staff and that staff had always been polite and respectful towards them. They said staff had talked to them about their care and treatment and had always gained their permission before providing them with any care and support.such as with bathing.

People told us they had been well cared for by staff at the home and that staff had supported them to attend appointments including with their GP and at the hospital.

People knew about their care records and plan and said they thought staff knew their needs well. They said they had enjoyed organised activities within the service and also trips out with staff.

People told us they knew how to complain and would do if they needed to. They said they knew they would be listened to and were confident that their complaint would be properly dealt with. They told us they had no concerns about the way people had been treated and would report an incident of abuse right away.

People said staff were good at their jobs and they felt confident in their care. They said they thought staff were well trained and properly supervised. People told us that staff had regularly approached them and had asked if they had any concerns or other comments about the service they received.

We also spoke with the local authority and they did not raise any concerns about the service.

This inspection followed on from a general inspection that was held the week before. Comments during that review were positive from individuals and their families about the standard of care provided.

For this visit we were accompanied by an expert by experience. The expert spoke with people and relatives and made observations in respect of the care provided at the service. The expert's observations included:

'Residents all had various stages of dementia although some were able to speak with me.

The residents as far as they are able to express their views and are able to have the privacy of their own room, when they require it'.

'I spoke to a relative of a service user who said that the staff were fantastic and she was involved with her father's care plan when he came into the home five years ago”.This gentleman had been in both parts of the home during those five years'.

'The staff appeared to be very caring and had empathy with the residents'

'Both relatives and residents I spoke to could not speak highly enough of the staff and the way they empathised with the residents'.

TThe majority of people living in the service told us that they were treated well by the careworkers and that care workers were "lovely", "kind" and "look after me well". A relative visiting the service told us that, "the care workers are excellent, I can not fault them".

During our visit we saw several situations that demonstrated that the service was not promoting choice and respecting people's privacy and dignity. One person living in the service was observed to be alone in the garden. The person was in a neglected state without footwear, dirty clothing and dried faeces on their hands. We spoke to care workers who told us that they had tried to get the person to change and wash. They told us that the person often did not want personal care. When we looked in the persons care records we could find no information that told us that the person refused personal care on any occasion. A record was produced that showed us that care workers had tried once that day to deliver personal care for the person but not further efforts or other actions had been taken to deliver appropriate personal care. The person had walked through the conservatory in the service to get in the garden. The conservatory had care workers in attendance at the time. Care workers had clearly observed the person accessing the garden area without appropriate footwear and taken no action to maintain their safety. Care workers were aware of the person and their appearance but had not taken sufficient action to maintain the person's dignity

One person temporarily living in the service had their medication managed by the service. The person told us that they would prefer to manage their medication themselves. Care workers had wanted to manage the person's medication as they thought it was safer. The person's wishes to manage their own medication had not been taken into account.

Following this visit we asked the service to make 5 safeguarding referrals to social services informing them of allegations of neglect observed at this visit. The service agreed to make these referrals and did so.

During the visit we spoke to people about their dietary needs. In general people thought that the food was of good quality and enjoyed what was provided.

We saw that information to people to help them a choice about the food that they received was in accurate. On the day of our visit a cooked breakfast was not served until 10.30 am. In recent months breakfast has been set to be given at 10 am. People we spoke with said this was the first thing they had, had to eat and drink that day and three told us that they were hungry. A relative told us that they thought breakfast was far too late even at 10 am and that lunch was at 1pm. They thought that breakfast and lunch were too close together.

Several people spoken with were able to tell us that they got up at 6am or 7am. They were able to get themselves up washed and dressed and did not need care workers assistance to do so.

At the evening meal we observed care workers give people their savoury dish at the same time as their dessert. This practice is dated and institutional; when we asked care workers and the manager why care workers had served food in this manner they were unable to offer an explanation.

Our inspection team was made up of two inspectors. We considered our inspection finding to answer questions we always ask:

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well-led?

This is a summary of what we found –

Is the service safe?

People’s care had been properly assessed and planned for and staff had the information they needed to provide people with safe and effective care and support.

Staff had received training in emergency procedures and they were confident about what to do in an emergency situation.

People who used the service were put at risk of abuse because safeguarding procedures were not appropriately followed.

Is the service caring?

People who used the service told us that they were treated well and that staff were kind.

Staff did not always treat people with respect, for example staff served food and drinks to people who used the service in an undignified way.

Staff did not take in to consideration people’s individual needs when providing them care and support. For example people were left sitting in their wheelchairs and waited for over an hour for their breakfast.

Is the service effective?

People’s care records were updated which ensured staff had all the information they needed to provide people with the right care and support.

People had access to a complaints procedure and they told us they would complain if they needed to.

Is the service responsive?

People did not always receive person centred care and support because staff did not respond to people’s individual needs.

Staff responded appropriately when they had concern about people’s health and wellbeing.

Is the service well-led?

The registered manager failed to follow the provider's and the local authority's safeguarding procedures, therefore putting people at risk of abuse.

Systems in place to regularly assess and monitor the service provision which people received, were not fully effective because they failed to identify issues relating to recruitment procedures.