We carried out a comprehensive inspection of Beaufort Grange in November 2016. At this inspection, we found breaches in the legal requirements relating to quality assurance and record keeping. We undertook a focused inspection in July 2017 in response to concerns raised by relatives, staff and health professionals regarding the staffing and management of the home. We found a further breach of the regulation relating to staffing. Following both inspections, the provider wrote to us and told us the actions they were taking to meet the legal requirements of the Health and Social Care Act 2008.

We carried out a comprehensive inspection on 15 November 2017 and reviewed the improvements that had been made since our last inspections.

Beaufort Grange is a 74 bedded home that provides accommodation for persons who require nursing and personal care. At the time of our inspection there were 38 people living in the care home.

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.

Overall, we found there had been significant improvements and the legal requirements had been met. Further work was needed to ensure that improvements were consistent, embedded and sustained.

Sufficient numbers of staff were deployed at the time of our visit when the home was only 51% occupied. Staff performance was effectively monitored. Staff had received supervision and training to ensure they could meet people’s needs.

People’s medicines were managed safely and audits and checks were completed. Actions were taken when errors were identified.

People’s dietary requirements and preferences were recorded and people were provided with choices at mealtimes.

Staff were kind and caring. We found people were being treated with dignity and respect and we found people’s privacy was maintained.

Systems were in place for monitoring quality and safety and actions were taken where areas for improvement and shortfalls had been identified. Further improvements were needed to make sure shortfalls were promptly recognised and acted upon.

We carried out a focused unannounced inspection of Beaufort Grange on 5 June 2017. Prior to this inspection, we had received concerns about the health. safety and welfare of people living in the home. The concerns related to how the home was being staffed and the management arrangements in place to provide support and direction to the staffing teams.

We undertook this focused inspection to ensure that people living in the home were safe, and that there were sufficient staffing and management arrangements in place to make sure people’s care needs were being met. This report only covers our findings in relation to these areas. You can read the report from our last comprehensive inspection, by selecting the ‘All reports’ link for Beaufort Grange on our website at www.cqc.org. The current overall rating for the home is ‘Requires Improvement.’

Beaufort Grange is registered to provide accommodation for up to 74 people who need nursing or personal care. At the time of our visit, 45 people were living in the home.

There was a manager who was registered with the Care Quality Commission to manage this service. However, they were no longer in post at the time of our visit. Their deregistration process had not been completed. ‘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.

People who used the service and their relatives provided mixed feedback about staffing. Staff turnover and significant reliance on agency staff meant that people could not always be confident their care needs would be met.

There were sufficient management arrangements in place. However, these were temporary arrangements. People and staff were not confident the improvements that had been made would be sustained and embedded in the home.

We found one breach 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 the report.

We carried out a comprehensive inspection of Beaufort Grange on 11 August 2015. During this inspection, we found six breaches of the Health and Social Care Act 2008. Following this inspection in August 2015, the registered manager in post at the time wrote to us to say what they would do to meet the legal requirements of the Health and Social Care Act 2008.

During January 2016 and February 2016, we received a significant number of concerns about staffing levels and care provision at Beaufort Grange. This information of concern was received from people living at the service, their relatives, staff and from healthcare professionals who had visited the service. As a result of this information we undertook a further comprehensive inspection of Beaufort Grange on 23 February 2016. During this inspection we followed up on the breaches we identified during the inspection in August 2015. You can read the reports from our last comprehensive inspections, by selecting the 'All reports' link for ‘Beaufort Grange, on our website at www.cqc.org.uk.

During the inspection in February 2016, we found eight breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. As a result of this the service was rated as ‘Inadequate’ overall, the service was therefore in ‘Special measures’. Services in special measures are kept under review. In addition to being placed in special measures, we imposed a condition on the provider’s registration around the assessment of people’s personal care, treatment and medicine needs, internal governance arrangements and recruitment progression.

We carried out a comprehensive inspection of Beaufort Grange on 4 October 2016 to review what improvements had been made at the service since they were placed into special measures following our inspection in February 2016.

Beaufort Grange provides accommodation for people who require nursing or personal care up to a maximum of 74 people. At the time of our inspection, 47 people were living at the service. Following our inspection in February 2016, the provider had placed a voluntary cessation on the admission of new people to the service. The current general manager told us this cessation remained in place and that the Commission would be contacted prior to any people being accepted at Beaufort Grange.

There was a not a registered manager in post during this 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. The current general manager had submitted all necessary application documentation to the Commission and was awaiting an interview as part of their registration process to become the registered manager.

During this inspection, we found that although governance arrangements and systems had been improved, there was still no effective system in operation to monitor daily records made by staff. We identified that some people’s medicines records, food and fluid charts and repositioning records had not always been completed accurately. Care records did not consistently reflect people’s needs. Despite staff being able to demonstrate an awareness of people’s care needs and risks, people were still not fully protected against the risks associated with poor record keeping.

Through conversations with people and their relatives it was evident they were experiencing a better quality of living than they were during the previous inspections of this service. People and their relatives said they felt safe at the service and commented positively on the staff that supported them. Care records had been updated and reflected the risks associated with people’s care, however we have made a recommendation about the planning of diabetes care. Incident and accident

We carried out a comprehensive inspection of Beaufort Grange on 11 August 2015. During this inspection, we found six breaches of the Health and Social Care Act 2008. Following the inspection in August 2015, the registered manager wrote to us to say what they would do to meet the legal requirements of the Health and Social Care Act 2008. They told us they would meet all of the regulations by 31December 2015.

During January 2016 and February 2016, we received a significant number of concerns about staffing levels and care provision. This information of concern was received from people living at the service, their relatives, staff and from healthcare professionals who had visited the service. As a result of this information we undertook a comprehensive inspection of Beaufort Grange on 23 February 2016. As part of this inspection, we checked to see if the service was meeting the legal requirements for the six regulations they had breached at our inspection in August 2015. You can read the report from our last comprehensive inspection, by selecting the 'All reports' link for ‘Beaufort Grange, on our website at www.cqc.org.uk.

Beaufort Grange provides accommodation for people who require nursing or personal care to a maximum of 74 people. At the time of our inspection, 67 people were living at the service.

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.

The provider had not ensured there was enough staff on duty to meet people’s needs. There was inconsistency in undertaking an accurate assessment of the risks to people’s health and safety. This placed some people living at the service at risk of receiving unsafe or inappropriate care or treatment. We also found there were issues of concern around the management and safe administration of medicines. The service was not consistently clean and appropriate systems were not in operation to reduce cross infection risks.

The provider had not implemented sufficient measures to ensure that people’s nutrition and hydration needs were consistently met. We made observations that the dining experience for some people was not enjoyable due to insufficient numbers of staff being available to support people. The service had not fully complied with the requirements of the Deprivation of Liberty Safeguards (DoLS). DoLS is a framework to approve the deprivation of liberty for a person when they lack the mental capacity to consent to treatment or care and need protecting from harm. This placed people at risk of being unlawfully deprived of their liberty. In addition to this, the provider was not providing care in line with people’s consent and with mental capacity legislation.

Not all staff put into practice their knowledge of promoting people’s privacy and dignity. We observed good interactions between people and staff. However, we made observations where people’s dignity was not properly maintained and communication between staff and people was not caring and reassuring when people were distressed or anxious. The provider had not been consistently responsive to people’s needs and we saw examples of poor care being provided and other care not being given in line with people’s assessed needs. We saw that some care provision had not been designed in line with people’s preferences. There were insufficient governance systems to monitor the health, welfare and safety of people. Inaccurate records also placed people at risk of receiving inappropriate or unsafe care or treatment.

Staff we spoke with were knowledgeable about procedures around safeguarding and whistleblowing. The permanent staff we spoke with understood the needs of the people they cared for and the provider had

We undertook an unannounced inspection of Beaufort Grange on Tuesday 11 August 2015. When the service was last inspected in July 2014 there were no breaches of the legal requirements identified. Beaufort Grange provides accommodation for people who require nursing or personal care to a maximum of 74 people. At the time of our inspection, 63 people were living at the service.

A registered manager was not in post at the time of 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. A new general manager had assumed post on 6 August 2015 and advised us they would be applying to register as the manager in the very near future.

The provider had failed to consistently ensure that sufficient staff were available to meet the needs of people safely. People, their relatives and staff raised concerns about the current staffing levels at the service and gave examples of how this had impacted on people’s care provision.

Risks to people were assessed, however guidance for staff on how to keep people safe was not always clear and it was not always possible to easily view the most up to date information about the person. Some assessments we reviewed contained conflicting information to reduce risks to people. Falls and incident management did not always effectively highlight areas of possible risk reduction.

The service had not consistently met people’s nutritional and hydration needs or preferences. People gave mixed views about their dining experience and staff gave examples of how the current staffing levels had an impact on meeting people’s nutritional needs. Nutritional monitoring did not ensure people were fully protected from the risks of malnutrition and supporting records were variable in accuracy.

We found the service had not been consistently responsive in meeting people’s needs in relation to wound care through failing to following professional guidance. Where assessments had given staff guidance on how to be responsive to people’s communication needs, this had not always been followed.

The provider had governance systems to monitor the health, safety and welfare of people these were not always accurate or used correctly. The provider had failed to ensure the service had submitted the correct legal notifications to the Commission as required.

People we spoke with and their relatives gave positive feedback about the service and told us they felt safe. Staff were aware of how to identify and report suspected abuse and understood the concept of whistleblowing to external agencies.

The provider completed safe recruitment processes to ensure only suitable people were employed and people were cared for in a clean environment. Equipment to keep people safe was regularly maintained and medicines were administered safely.

Staff were supported through regular training and told us they felt sufficiently trained to provide effective care. We received mixed responses from staff about the supervision and appraisal they received but told us they could obtain support, guidance and direction when required. The provider had an induction programme aligned to the new Care Certificate.

The manager was aware of their responsibilities in regard to the Deprivation of Liberty Safeguards (DoLS). DoLS is a framework to approve the deprivation of liberty for a person when they lack the mental capacity to consent to treatment or care and need protecting from harm. Staff understood the Mental Capacity Act 2005 and how it impacted on their work. We saw examples of where the service had involved healthcare professionals and advocacy services in best interest decisions for people.

Staff knew the people they were caring for well and we received a high level of feedback and praise for the staff employed at the service. A national website used by people and their relatives and the compliments log at the service reflected the views of people in the service. People felt their privacy and dignity was respected and we observed examples of staff supporting people to maintain their dignity.

People’s care records were personalised and contained unique information about people. We saw positive examples of staff being responsive to people’s needs and demonstrated they knew people’s life history and preferences when doing this. The service had a mixed activities programme for people to be involved in and people or their relatives felt able to raise concerns or complaints within the service.

Staff told us they felt there was an open culture in the home and senior staff were approachable. Staff commented on a positive team ethos and told us they felt the current poor staffing levels had pulled them together as a team. There were systems to communicate with staff in operation and there were some effective systems to monitor the quality of service provision. The provider had additional internal quality monitoring systems completed by senior directors.

We found multiple beaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in multiple regulations. In addition, a breach of the Care Quality Commission (Registration) Regulations 2009 was also identified. You can see what action we told the provider to take at the back of the full version of this report.

During our inspections we set out to answer a number of key questions about a service: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

During this inspection we looked at the arrangements being made for gaining people’s consent. This helped us to answer the question Is the service safe? And is the service effective?

At the previous inspection of Beaufort Grange on the 28 and 29 April 2014 we had found that procedures were not always followed to ensure that consent was gained from people using the service and it was not recorded in their documentation, before receiving care and treatment. The service had not been complying with the regulation in relation to consent. We told the provider and the manager that they must take action to ensure that improvements were made.

We visited Beaufort Grange again on the 29 July 2014 order to check on the action that had been taken. Below is a summary of what we found.

Is the service safe?

We found that improvements had been made and we found the service was now complying with the regulation. People who used the service were now better protected against the risks associated with medicines. This was because the provider now had appropriate and robust arrangements in place for the recording and safe administration of medicines.

Is it effective?

We found that improvements had been made and we found the service was now complying with the regulation. People’s documentation now demonstrated how people had given their consent to their care and treatment decisions. This was because their care documentation detailed people's consent or best interest decisions. Documentation also evidenced the involvement of family members and other professionals as required.

The inspection team was made up of an inspector and a pharmacist. We set out to answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

At the time of our inspection 37 people were living in the home. We observed the care being provided to people in the communal areas of the home and examined the care documentation and supporting records. We spoke with nine people that used the service who were able to tell us of their experiences. We also spoke with eight members of staff to gain their understanding of how they met the needs of people living in the home.

Below is a summary of what we found.

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

Is it safe?

People told us they felt safe and well cared for. They told us “it’s a very lovely home I feel safe here”. We saw that people’s care needs were met in a safe way as moving and handling equipment was used appropriately.

Safeguarding procedures were in place and staff understood their role in safeguarding the people they supported. One person we spoke with told us they felt safe living in the home and observations that we made evidenced that staff supported people in a safe manner with their moving and handling needs. People who used the service were cared for by staff who knew how to protect them from the risk of abuse.

Staffing was maintained at safe levels. The registered manager set the staff rotas; they took people’s care needs into account when making decisions about the numbers, qualifications, skills and experience required. The registered manager told us extra staff could always be provided across the home if required. We viewed this during our inspection. Extra staff were provided in the Memory Lane area of the home. We were told this was because more people required one to one support at this particular meal time. This ensured that people’s needs were met safely.

Recruitment practice was safe and thorough. No staff had been subject to disciplinary action. Policies and procedures were in place to ensure that unsafe practice was identified and people were protected. Staff understood the procedure in place to report unsafe working practice.

The home had policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards (Dols). The registered manager confirmed no one currently living in the home was subject to a Dols application. However relevant staff had been trained to understand when an application may be required and the registered manager told us about times when they had sought advice in the past from the Dols team. The organisation was introducing a new system of assessment in relation to Dols. This meant that people would be safeguarded as required.

Medicine management systems were not robust in relation to the recording and safe administration of medicines. We have asked the provider to tell us what they are going to do to meet the requirements in relation to medicines.

Systems were in place to make sure that managers and staff learn from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helps the service to continually improve people’s safety.

Is it caring?

People were supported by sensitive and attentive staff. We saw that care staff showed patience and gave encouragement when supporting people. Not everyone was able to verbally tell us of their experience of living in Beaufort Grange. Therefore we spent a period of time observing interactions between staff and people that used the service.

The observations we made demonstrated staff supported people in a calm unhurried manner, using communication methods conducive with their individual assessed needs. People were consulted before staff undertook their care routines. A member of staff was heard to ask a person “would you like me to help you with X”. “Would you like to try something else to eat as you didn’t eat a lot of that”.

Staff were respectful of people’s privacy and were heard knocking on people’s doors prior to entry.

Is it effective?

People living in the home were positive about the care they received. Comments included: “they are fabulous here”, “I am extremely happy here”, “It’s nice, they do their best” and “Food choices are very good”.

We found people’s health and care needs were assessed, but some documentation lacked evidence of how or if people were formally consulted in their care and treatment decisions. This was because some care documentation lacked details of people’s consent or best interest decisions. We have asked the provider to tell us what they are going to do to meet the requirements in relation to consent.

It was clear from our observations and from speaking with staff that they had a good understanding of people's care and support needs and that they knew them well. This was confirmed by observations that we made and discussions we had with members of staff.

Is it responsive?

People's needs had been assessed before they moved into the service. The registered manager told us people met with their key workers monthly to discuss their care plans as part of a system called ‘resident of the day’. This was a system that ensured staff from all departments met with the person to discuss the service provided.

People received co-ordinated care. We saw evidence in people's care plans that demonstrated people had been visited by their GP and other health care professionals. People we spoke with confirmed they had access to a GP as and when they required one. One person told us “I just tell the staff and they will ring for me”.

People knew how to make a complaint if they were unhappy. One person told us “Oh yes my dear I would happily tell the manager”. We looked at the complaints procedure and found it to be robust. Therefore people could be assured that complaints would be investigated in a timely manner.

Is it well-led?

People that used the service and their relatives completed a satisfaction survey once a year and posted testimonials on the organisations website. The registered manager told us if any concerns were raised these would be addressed promptly with the person on a one to one basis. Comments received from people included: “I have a real say in how staff care and support me”. “I cannot fault the home, the atmosphere is a very happy one, and more importantly the staff appear happy in their work”.

Some people we spoke with were able to tell us their experience. They confirmed they felt listened to by staff and knew how to raise a complaint if they needed to.