Alice Grange provides nursing care for up to 88 younger adults and older people. The service is supporting people with a range of needs which includes; people living with dementia and those who have a physical disability or require palliative care. There were 70 people living in the service when we inspected on 27 April and 2 May 2017. This was an unannounced inspection.

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 2008 and associated Regulations about how the service is run.

At our last inspection in February 2016, we found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was in relation to staffing arrangements not being consistent to ensure there was sufficient numbers of staff to meet people’s care and welfare needs. At this inspection we found that staffing levels had improved although views about this remained mixed. People told us they received attention promptly when they called for assistance. However some people raised concerns that there were times when staffing levels could be improved, particularly at weekends and at meal times.

There were systems in place to minimise risks to people and to keep them safe. However, there were some risks associated with people’s health conditions which needed further explanation. Care records needed to be strengthened to ensure all staff were aware of the risks and how they should support people accordingly.

There was a positive, open and inclusive culture in the service. The atmosphere in the service was warm and welcoming. The management team led by example.

Staff understood the importance of gaining people’s consent and were compassionate, attentive and caring in their interactions with people. They understood people’s preferred routines, likes and dislikes and what mattered to them. People were involved in making decisions about their care.

The management team and staff understood their responsibility to comply with the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). 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.

People presented as relaxed and at ease in their surroundings and told us that they felt safe. Procedures were in place which safeguarded the people who used the service from the potential risk of abuse. People knew how to raise concerns and were confident that any concerns would be listened and responded to.

People were complimentary about the way staff interacted with them. Independence, privacy and dignity was promoted and respected. Staff took account of people’s individual needs and preferences and people were encouraged to be involved in making decisions about their care.

Care plans were written in a person centred manner and reflected the care and support each person required and preferred to meet their assessed physical needs. More information was needed to guide staff how to support people’s emotional and social needs. Shortfalls in the care plans had been identified by the providers own audits and these were in the process of being updated.

People’s nutritional needs were assessed and professional advice and support was obtained for people when needed. They were supported to maintain good health and had access to appropriate services which ensured they received on-going healthcare support.

People were provided with their medicines in a safe manner. They were prompted, encouraged and reassured as they took their medicines and given the time they needed.

The service had a quality assurance system in place which was used to identify sho

Alice Grange is a purpose built care home providing nursing care for up to 85 younger adults and older people. The service provides support to people with a range of needs which include; people living with dementia, those who have a physical disability, and/or people who require palliative end of life care.

There were 67 people living in the service when we inspected on 24 February 2016. This was an unannounced inspection.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in relation to ensuring people were consistently supported by sufficient numbers of staff who are effectively deployed and have the knowledge and skills to meet people’s needs. We found that there were occasions, for example at meal times where staffing levels were not sufficient to ensure people had a good mealtime experience. In addition that people with complex needs had staff available to support them to spend their day in a meaningful way. You can see what action we told the provider to take at the back of the full version of this report.

Improvements had been made to the leadership of the service. This had led to the overall quality of the service improving. The service’s development plan had been effective and was being added to ensure that this continued, was sustained and drove improvement. There was a more positive culture in the service which meant that staff were aware of the values of the service and understood their roles and responsibilities.

People and relatives were complimentary about the care and support provided. Staff respected people’s privacy and dignity and interacted with people in a kind and compassionate manner. They were knowledgeable about people’s choices, views and preferences and acted on what they said. The atmosphere in the service was friendly and welcoming.

Procedures were in place which safeguarded the people who used the service from the potential risk of abuse. Staff understood the various types of abuse and knew who to report any concerns to.

Robust recruitment checks on staff were carried out. Staff were trained and supported to meet the needs of the people who used the service. They knew how to minimise risks and provide people with safe care. Procedures and processes guided staff on how to ensure the safety of the people who used the service. These included checks on the environment and risk assessments which identified how risks to people were minimised.

Appropriate arrangements were in place to ensure people’s medicines were obtained, stored and administered safely. However improvements were needed in the medicines administration records to ensure consistency and that people were protected.

People’s nutritional needs were being assessed and met. Where concerns were identified about a person’s food intake appropriate referrals had been made for specialist advice and support. People were encouraged to attend appointments with other healthcare professionals to maintain their health and well-being.

People or their representatives were supported to make decisions about how they led their lives and wanted to be supported. Where they lacked capacity, appropriate actions had been taken to ensure decisions were made in the person’s best interests. The service was up to date regarding the Deprivation of Liberty Safeguards (DoLS).

Care and support was based on the assessed needs of each person. However this information was not always reflected in people’s care records to ensure best practice was followed

People’s experience of how they spend their days was inconsistent. Whilst there were some areas of good practice with regards to activities and social stimulation there were also several instances where people were left for periods of time with little or no interaction. Improvements were needed to ensure people especially those living with dementia spent their time in meaningful and fulfilled ways

Processes were in place that encouraged feedback from people who used the service, relatives, and visiting professionals. There was a complaints procedure in place and people knew how to make a complaint if they were unhappy with the service.

We carried out an unannounced comprehensive inspection of this service on 27 November 2014. We found shortfalls in the recording and safe administrations of medicines, inappropriate documentation used for recording well-being checks on people. There were inconsistencies in the recording of people’s care plans to show how they were involved in decisions about their care and quality monitoring systems were not robust.

Following this inspection, the provider wrote to us to say what improvements they planned to make to address our concerns.

We undertook this focused inspection to check that they had followed their improvement plan.  We found that some progress had been made to address our concerns. This report only covers our findings in relation to the sections Safe, Responsive and Well-led where we identified shortfalls. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Alice Grange on our website at

www.cqc.org.uk

Alice Grange is a purpose built care home providing nursing care for up to 85 younger adults and older people. The service provides support to people with a range of needs which include; people living with dementia, have a physical disability, or require palliative care.

At the time of our unannounced focused inspection on 11 August 2015, there were 62 people living in the service.

There was no registered manager at Alice Grange. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.  Since our last inspection another new manager had been appointed by the provider to run the service and was in the process of registering with the CQC.

Continued progress had been made to the management of medicines. Appropriate arrangements were in place for the recording and safe administration of medicines.  However improvements were needed for the management of medicines that were prescribed ‘as required’ (PRN) and homely remedies to ensure systems are robust.

Appropriate documentation had been implemented to record well-being checks for people. However inconsistencies remained in the recording of how people were involved in decisions about their care. Care plan audits identified that people and relatives were involved in the review process but this was not consistently reflected in people’s care plans.

The provider had taken steps to mitigate the risks to people and address the shortfalls found at the last inspection. This included implementing systems to monitor the quality and safety of the service. However these need measures to be embedded and sustained over time to ensure people are provided with a consistently safe quality service.

Alice Grange is a purpose built care home providing nursing care for up to 85 younger adults and older people. The service provides support to people with a range of needs which include; people living with dementia, have a physical disability, or require palliative care.

This was an unannounced inspection which took place on 18 November 2014 and 27 November 2014. At the time of our inspection there were 63 people who used the service.

At the last inspection on 29 May 2014 and 5 June 2014, we asked the provider to take action to make improvements relating to the care and welfare of people who used the service, supporting workers and assessing and monitoring the quality of service provision. Following the inspection the provider sent us an action plan advising us of how they planned to address these shortfalls.

We carried out a focussed inspection on the 5 August 2014 after we received concerns about the management of medicines at the service. Our pharmacist inspector found that people were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place for the recording, handling, using and safe administration of medicines. We had also been notified of concerns that indicated people had not received their medicines as prescribed. The provider sent us an action plan to tell us the improvements they were going to make.

During this inspection we looked to see if the shortfalls identified at the previous inspections had been made. We found that some progress had been made to address our concerns.

At the time of our inspection there was no registered manager at Alice Grange. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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. A new manager had been appointed by the provider to run the service and was in the process of registering with the CQC.

People that we spoke with told us they felt safe, were treated with kindness, compassion and respect by the staff and were happy with the care they received.

Staff knew how to recognise and respond to abuse correctly. People were protected from the risk of abuse because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. Risks associated with people’s care needs were assessed and plans were in place to minimise the risk as far as possible to keep people safe.

There were sufficient numbers of suitably skilled staff to meet people’s care needs. Improved processes had been made and were on going to support staff and provide them with the knowledge and skills to carry out their roles and responsibilities.

While we found improvements in the management of medicines, people were not fully protected against the risks associated with the management of medicines because the provider did not have appropriate arrangements in place for the recording and safe administration of medicines. Improvements were required in the recording of medicines. People who were unable to give consent to their medicines being given to them disguised in food and drink should have a documented capacity assessment.

People were supported to access health care according to their individual needs. People’s care records provided information to staff on how to meet their needs, promote their independence and maintain their health and well-being. However not all the care plans reflected how people were involved in making decisions about their care.

While we found improvements had been made in the monitoring and recording of people’s nutritional needs, people were at risk of not receiving personalised care as the documentation used to record well-being checks were not always fit for purpose.

CQC monitors the operation of the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS), and to report on what we find. DoLS are a code of practice to supplement the main Mental Capacity Act 2005. These safeguards protect the rights of adults by ensuring that if there are restrictions on their freedom and liberty these are assessed by appropriately trained professionals. The provider was meeting the requirements of the DoLS. People who could not make decisions for themselves were protected. Where a person lacked capacity Mental Capacity Act (MCA) 2005 best interest decisions had been made. DoLS were understood and appropriately implemented.

People were supported to be able to eat and drink sufficient amounts to meet their needs and encouraged to be as independent as possible. Where additional support was needed this was provided in a caring, respectful manner.

Staff interacted with people in a caring, respectful and professional manner. Where people were not always able to express their needs verbally staff responded to people’s non-verbal requests promptly and had a good understanding of people’s individual care and support needs.

People were supported with their hobbies and interests and had access to a range of personalised, meaningful activities. People knew how to make a complaint and confirmed their choices were respected.

Improvements had been made to assess and monitor the quality of the service provided. The views of the people who used the service, their relatives, staff employed at the service and visiting healthcare professionals had been sought and acted on where required.

The Commission has recently been notified of concerns relating to the management of medicines at the service. At this inspection our pharmacist inspector assessed if people’s medicines were being managed safely and if arrangements were in place to protect people against the risks associated with the unsafe use and management of medication.

We looked at how information in medication administration records and care notes for people living in the service supported the safe handling of their medicines. We found that not all medicines could be accounted for numerically by records and so we could not be assured people’s medicines were always being administered as intended by their prescribers. We found there to be evidence of a medicine given in error on the day of inspection. We noted inadequacies in supporting information and records which could have led to people not receiving their medicines appropriately and as intended by prescribers. The competence of some registered nurses handling and administering people’s medicines had not recently been assessed although the manager had identified this and was taking action.

We spoke with six people who used the service and two people's relatives to gain their views of the service provided. We also received information from three relatives who raised concerns with the standard of care provided and staffing levels.

People we met during our inspection told us that they were generally satisfied with the service they were provided with and said staff treated them well. One person said, “Not bad at all, could be worse.” Another person said, “I am away from home, but it is still homely…staff very good.” Another said that staff had, “Been very good.”

One relative praised the level of care given and told us that they had seen an improvement in their relative’s health and welfare. One relative told us that they, “Have no concerns,” over the standard of care their next of kin received as they felt they were, “Well looked after.”

We found there were issues with the staffing levels in the service, staff's knowledge of dementia care and information given in people’s care plans to support people’s dementia related needs. This had an effect on the care and support provided to the people used the service.

People we spoke with said they were happy with the way the service managed their medicines. We found that people were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place for the safe keeping, recording, obtaining and the management of medicines.

The people we spoke with told us that they liked living at Alice Grange. One person said "My friend who was living here told me how nice it was so I moved in". They all commented that the food was good and varied. One person said "That is a strong point here." They said that the staff were friendly and attentive. A relative told us that "some staff will go the extra mile to support people."

People told us they were satisfied with their care, and that the staff were good and kind. They said that the food was generally sufficient and varied, and those that were able could go out by themselves or with an accompanying volunteer.

The inspection team was made up of three inspectors on the first day of the inspection, and one inspector on the second day. The first day started at 4am which enabled us to look at the night time and early morning routines. On the second day we looked at the tea time and early evening routines. The timings of our inspections were linked to the concerns we had received from people who used, worked or had contact with the service. We focussed on the concerns that had been raised around; the management of the service, the skills of the staff and the completion of care records.

We spoke with seven people who used the service. We also spoke with 15 staff and received written feedback from three people’s relatives and four health and social care professionals. We looked at seven people’s care records. Other records viewed included information on staff training records, provider visit reports, staff rotas and health and safety policies. We considered our inspection findings 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?

One person told us how it had been difficult to make the decision to move into full time care, but were glad they had. They told us, “I feel safe here…well looked after, they (staff) pop in at night and say are you alright?”

People living in the service told us they were provided with a clean, safe, well maintained environment which met their needs.

Our observations identified that staff were not always maintaining good hand hygiene at meal times and we fed back to the manager that improvements were needed.

We found that people’s care plans records did not accurately reflect the level of support that staff told us that they had given. This meant there was a risk that care was not being provided in a consistent way.

Staff were provided with training in safeguarding vulnerable adults from abuse, Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). We saw that the provider had put a system in place to assess if a DoLS referral was required to protect a person using the service. However, where required, staff had not made the referrals. The registered manager confirmed that action would be taken to ensure the referrals were made.

Is the service effective?

All the people we spoke with were positive about the quality of the food provided. One person told us at the lunch time and evening meal, “We have two choices of a starter and a main meal, a sweet and a cup of coffee.”

People confirmed that they were able to see their visitors in private and when they wanted to.

We found the quality of the information given in people’s care plans fluctuated. This was because some care plans provided guidance for staff, to support person centred care. However, the contents of other people’s care plans had not been updated and/or reflected people’s current care needs. Therefore it did not provide staff with enough guidance to provide appropriate personalised care. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

Is the service caring?

The majority of the feedback we received showed that people were supported by kind and attentive staff. One person who lived in the service told us that the staff always treated them in a kind and polite way. Another person told us, “Wonderful carers, couldn’t ask for better care.” Information received from one person identified where staff had not acted in a respectful or appropriate manner.

When we spoke with staff they demonstrated their commitment to provide a good service. During the morning shift change over we heard staff discuss people needs in a kind and respectful manner.

Is the service responsive?

People’s preferences and choices were usually taken into account and listened to. The staff involved people in making decisions and acted on the information they received. One person living in the service told us, “Your wishes are carried out, rather than what they (staff) want you to do.” However, we also saw there were some instances where the service needed to make improvements to ensure that people always felt listened to and had confidence that staff would act on what they said.

People’s care records showed that where concerns about their health and wellbeing had been identified that staff had taken appropriate action to ensure that people were provided with the support they needed. This included seeking support and guidance from healthcare professionals which included a doctor and community dietician.

Is the service well-led?

Not everyone we spoke with, or received information from, felt that the registered manager always listened to feedback given to improve the service. We found improvements were needed to ensure that information was shared between all levels of management and staff, as well as between people living in the service, their relatives and advocates.

The service had quality assurance systems in place and records seen by us showed that shortfalls were being identified but not acted on in a timely manner. As a result, the quality of the service was not continually improving. Instead, we found previous shortfalls which had been addressed by the provider, had re-occurred. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.