The inspection was carried out on 16 May 2017. Our inspection was unannounced.

Grace Manor Care Centre is a care home which is registered to provide accommodation, personal and nursing care for up to 60 people. The home is a listed building which has been extended. The home had two wings which had been named Medway view and Abbey suite. Accommodation is set out over two floors with lift access to the first floor. On the day of our inspection there were 56 people living at the home, including a married couple who moved to the home on the day of the inspection. People had a variety of complex needs including people with mental health and physical health needs and people living with dementia. Some people had limited mobility and some people received care in bed.

The service 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 2014 and associated Regulations about how the service is run.

At our previous inspection on 09 and 11 February 2016 we found breaches of Regulation 9 and Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider had not ensured that leadership and quality assurance systems were effective to make sure people were safe and they received a good service. Records were not accurate and complete. The provider had not ensured that people received appropriate care that met their needs and reflected their preferences. We also made a number of recommendations. We asked the provider to take action in relation to the breaches of regulations.

The provider sent us an action plan on 09 June 2016 which stated that they would comply with the regulations by 01 July 2016.

At this inspection we found there had been improvements to the home. People told us they received safe, effective care.

The home was in the process of being redecorated. The Abbey suite area of the home had been decorated to help people living with dementia orientate in their environment. Some people with dementia were living in the Medway View part of the home which had not been decorated in a manner to help them orientate. The provider told us that this was because people and their relatives living in this part of the home had chosen not to have a dementia friendly theme. However, some people were confused about their environment. People reported that other people often wandered in to their room at night and during the day. We made a recommendation about this.

The premises were well maintained, clean and tidy. The home smelled fresh.

Recruitment practices were safe and checks were carried out to make sure staff were suitable to work with people who needed care and support because employment checks and references had been gained before staff started their roles.

The safety of people was taken seriously by the registered manager and staff who understood their responsibility to protect people's health and well-being. Staff, including the registered manager, had received training about protecting people from abuse, and they knew what action to take if they suspected abuse. Risks to people's and staff member's safety both internally and externally had been assessed and recorded, with measures put into place to manage any hazards identified.

Staffing levels were kept under review to ensure staff were available to meet people's assessed needs.

Staff had a full understanding of people's care and support needs and had the skills and knowledge to meet them. People received consistent support from the same staff who knew them well. Staff were trained to meet people's needs. Robust induction procedures were in place to ensure staff were able and confident to meet people's needs. The provider encouraged staff to undertake additional qualifications to develop their skil

The inspection was carried out on 09 and 11 February 2016. Our inspection was unannounced.

Grace Manor Care Centre is a care home which is registered to provide accommodation, personal and nursing care for up to 60 people. In 2014 the home was refurbished. The home now has a reduced capacity to care for up to 51 people as everyone is offered a single room. The home is a listed building which has been extended. Accommodation is set out over two floors with lift access to the first floor. On the day of our inspection there were 46 people living at the home. People had a variety of complex needs including people with mental health and physical health needs and people living with dementia. Some people had limited mobility and some people received care in bed.

The service 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 2014 and associated Regulations about how the service is run.

At our previous inspection on 21 July 2015 we found breaches of Regulation 9, Regulation 10, Regulation 12, Regulation 15, Regulation 17, Regulation 18, Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and Regulation 18 of The Care Quality Commission (Registration) Regulations 2009. We issued four warning notices in relation to Regulation 10, Regulation 12, Regulation 17 and Regulation 18. We asked the provider to meet the regulations by 04 December 2015. We issued one warning notice in relation to Regulation 19 and asked the provider to meet the regulation by the 20 October 2015. We also asked the provider to take action in relation to Regulation 9, Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and Regulation 18 of The Care Quality Commission (Registration) Regulations 2009.

The provider sent us an action plan the day after we inspected the service which stated that they would comply with the regulations by 31 August 2015.

At the last comprehensive inspection this provider was placed into special measures by CQC. This inspection found that improvements had made which had moved the overall rating from inadequate to requires improvement, which was enough improvement to take the provider out of special measures. However, improvements to some areas were still required. As a result, they were breaching regulations relating to fundamental standards of care.

People and their relatives were positive about the service they received and had noticed improvements to the home.

Records relating to staff recruitment were not robust. Interview notes had not captured reasons for gaps in employment, even though staff confirmed that it had been discussed.

Effective systems were not in place to enable the provider to assess, monitor and improve the quality and safety of the service. Audits undertaken had not picked up the concerns about staff recruitment records and infection control we found during the inspection.

Records relating to care and support provided were not always accurate and complete.

People had not always been weighed in line with their assessed needs.

Staff had received training about protecting people from abuse and showed a good understanding of what their roles and responsibilities were in preventing abuse. However the policies, procedures and protocols for staff were out of date. We made a recommendation about this.

People’s safety had been assessed and monitored. However risks associated with access to unsafe areas such as the kitchen and store rooms had not been appropriately managed. The home was not clean in all areas. We made a recommendation about this.

People and their relatives knew who to talk to if they were unhappy about the service. When complaints had been received, these had been investiga

The inspection was carried out on 21 July 2015. Our inspection was unannounced.

Grace Manor Care Centre is a care home which is registered to provide accommodation, personal and nursing care for up to 60 people. In 2014 the home was refurbished. The home now has a reduced capacity to care for up to 52 people as everyone is offered a single room. The home is a listed building which has been extended. Accommodation is set out over two floors with lift access to the first floor. On the day of our inspection there were 51 people living at the home. People had a variety of complex needs including people with mental health and physical health needs and people living with dementia. Some people had limited mobility, pressures ulcers and some people received care in bed.

The service did not have a registered manager. The previous registered manager had ceased working at the service in March 2015. The new manager had made an application to become registered with the Care Quality Commission.

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 2014 and associated Regulations about how the service is run.

At our previous inspection on 07 August 2014 we found a breach of Regulation 21 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. This corresponds with Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 which came into force on 1 April 2015. We asked the provider to take action in relation to safe recruitment practice.

The provider sent us an action plan on 06 November 2014 which stated that they would comply with the regulations by 14 November 2014.

At this inspection we found that improvements had been made within the timescales they had given us. However, the improvements had not been sustained. As a result, they were breaching regulations relating to fundamental standards of care.

Effective recruitment procedures were not in place to ensure that potential new staff employed were of good character and had the skills and experience needed to carry out their roles.

There were not enough staff deployed to ensure that people received care and support in an effective and timely manner.

Accident and incidents were not always thoroughly monitored and investigated appropriately. Risk assessments lacked detail and did not give staff guidance about any action staff needed to take to make sure people were protected from harm.

Medicines administered were not adequately recorded to ensure that people received their medicines in a safe manner.

The training staff received did not give them the skills to support people effectively. For example, moving and handling practice we observed was not safe and put staff and people at risk of harm. Staff did not have access to all the information they needed about how to report abuse.

Meals and mealtimes did not promote people’s wellbeing. People’s health care was not planned or delivered effectively. People were not treated with dignity and respect or provided with personalised care. Staff were not responsive to people’s needs or choices. People were not provided with meaningful activities. People were at risk of social isolation, they had limited contact with the local community. There was an institutional culture.

Decoration for the home did not follow NICE good practice guidelines for supporting people who live with dementia.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Deprivation of Liberty Safeguards (DoLS) applications had been made to the local authority and had been approved.

People were supported and helped to maintain their health and to access health services when they needed them.

People and their relatives knew who to talk to if they were unhappy about the service.

Relatives and staff told us that the home was well run. Staff were positive about the support they received from the senior managers within the organisation. They felt they could raise concerns and they would be listened to.

Communication between staff within the home was good. They were made aware of significant events and any changes in people’s behaviour. Handovers between staff going off shift and those coming on shift were documented.

We found breaches 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.

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.

Services placed in special measures will be inspected again within six months. The service will be kept under review and if needed could be escalated to urgent enforcement action.

The inspection was carried out over a period of nine hours by two inspectors. There were 47 people who lived at the home on the day of inspection. They had a range of needs including difficulties with mobility and communication. Some of the people who lived in the home had dementia. This meant they were not always able to tell us about their experiences.

This report is based on our observations during the inspection, talking with two people who lived in the home, one visitor, two relatives and nine staff members. We spoke with the manager and reviewed records. We also met with the operations manager and the chief executive.

During this inspection 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?

Below is a summary of what we found. If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

Staff told us that they understood their responsibilities for reporting concerns and we saw that appropriate training and guidance was in place to ensure that people were protected from harm. The home’s safeguarding policy was detailed and provided suitable guidance for staff concerning how to protect people from risk of harm.

Some of the processes for the recruitment of staff to work at the home were not effective in ensuring that all of the checks that are required had been carried out. Not all staff members had provided a full employment history and documents verifying the identity of staff were not always in place.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. We spoke with the manager about the applications they had made to the court of protection under the Deprivation of Liberty Safeguards. They demonstrated a sound understanding of the circumstances that would mean an application needed to be made. This meant that appropriate applications were made when necessary.

Is the service effective?

We saw that people’s needs were assessed and care was delivered to meet their documented care needs. Staff we spoke with understood people’s care needs and demonstrated that they knew how to meet people’s needs and what to do if they noticed any changes or concerns. When appropriate, other professionals were involved in the care and treatment of people who lived at the home.

Is the service caring?

People were supported by staff who were kind and attentive. We saw positive interactions between staff and the people they supported. People who required help with eating were supported at their own pace. We saw positive interactions between staff and the people they supported. One staff member told us that “Everyone cares” and that they would have their own mother at the home.

Is the service responsive?

We found that the manager of the home acted to address concerns as soon as they were noted. People had access to activities they enjoyed and they were able to make suggestions concerning what they would like to do at residents’ meetings. People were given forums for making their views known and suggestions were acted on when possible. People who lived at the home had contributed to decisions about how the home was decorated and they were consulted about decisions wherever possible.

Is the service well-led?

Staff we spoke with told us that the manager of the home was approachable and they were able to seek advice and guidance whenever it was required. We looked at the way the quality of the service was assessed and monitored. We found that a number of audits were carried out to ensure that appropriate standards of care were maintained. People had opportunities to make their views known.

Our inspection of 27 September 2013 found that the staff team had not had all the training that they required, including dementia care training and that staff induction was not completed in a timely manner. At our visit on 5 March 2014 we found that the home had taken action to ensure that staff induction was comprehensive and that care and nursing staff obtained the statutory and specialist training that they required to care for the people who lived at the home.

An expert by experience accompanied us on this visit. They observed care practices in the home, spoke to a number of staff, three visitors and five people who lived in the home. Their experience of the home is included in this report.

Staff communicated with people who lived in the home in a respectful manner, and maintained people’s privacy. One person told us, “The staff are always friendly and welcoming”.

People had plans of care in place that identified their needs and gave clear guidance for staff to follow. Most visitors said that they had been involved in their relatives care and treatment. However, care plans had not been signed to evidence this.

People were complimentary about the staff team. One relative told us, “The staff treat her well”. Compliments received by the home included,” Friends thats what you are. May I and my family express our grateful thanks for the kindness and special care that you gave”.

People were supported to take their medicines safely.

The staff team had not had all the training that they required, including dementia care training, to support the needs of the people in the home.

The home had systems in place, including asking people who lived in the home for their views, in order to assess the quality of the service.

Staff were knowledgeable about people’s health, personal and nursing care needs. However, written records were not always accurate which could potentially lead to people not receiving the specific care that they required.

People were offered food choices according to their individual needs and preferences. One person told us, “The food is always very good here”. Another person told us, “I can have a drink or a snack when I want it”. However, records of food were not always legible and fluid charts had not always been totalled on a weekly basis to assess if people were receiving the amounts of fluid that they required to remain hydrated.

People who required help with being moved and handled told us that staff explained what they were going to do, and gained their verbal consent before starting the task with them. People who we spoke to in their bedrooms, told us that they preferred to spend their time in their rooms. They said that staff came in regularly to check that they were alright. People told us that staff came to support them when they rang the call bell for assistance. We observed staff responding quickly when they were approached by someone who was concerned about a person's well being.

We spoke to five people about what they did with their time during the day. Two people told us that they liked to watch TV in their bedrooms. Two people told us that they were bored. One of these people told us, "There is no stimulation" and the other person agreed with this statement. The fifth person we spoke to told us that they had planned to leave the home, but had now decided to stay at Grace Manor.

People said that, for most of the time, staff were not rushed. We were told that on some mornings it took a while to get all the people washed and dressed on the Haven unit, as many people required the assistance of the two members of staff that were available. We were told that a third staff member was stationed in the lounge to maintain people’s safety.

At lunchtime we observed people in the Haven unit, for people with dementia, using our Short Observation Framework for Inspection (SOFI). We saw that there were enough staff on duty to help people who needed support to eat. We saw that staff were able to take their time supporting people appropriately, and that they did not rush.

People and relatives told us that they felt confident to go to a member of the management team if they had any concerns about the care or treatment of any person who lived in the home.

People's comments about the home were mixed. For example, one person told us that they did not like living in the home. Another person told us, "I like it here. They look after us very well. I like watching the opera”.

Positive comments about the staff team included:

"Staff are lovely… they always see that I have not got any tea and they give me some more".

“They are all lovely people; they are good to us.” “Happy.”

People told us that they enjoyed it when the activities person came and sat and talked with them.

Other comments were:

“There are too many staff changes. The staff don’t always care. They don’t give me enough attention.”

One person told us that they could not find their call bell to summon help should it be needed. They said that when this happened they shouted for help and that this usually worked for them.

People's comments about the food in the home were mixed. People told us that the home was generally peaceful, although it could be noisy on occasions.

One person told “I am not happy in this room. There is not always any hot water. I want to move back upstairs when the refurbishing has been done.”

Relatives told us that the home did not always listen to them when they made a complaint. One person told us, "I have raised lots of concerns but they are not listened to. Nothing gets done".

Comments by people who lived in the home in the home's quality assurance questionnaires included:

“They ask me when I want to get up and go to bed, and knock on my door before entering”

"I'm happy here it is lovely".

"I like my room".

"The entertainment is quite good".

"I like most of the carers".

“They look after me well.”

“The housekeepers are good but are short staffed. All the staff are friendly.”

“I am quite happy here.”

"The staff are the best – they look after me.”

"I would like some more activities to join in".

“They don’t spend much time with me.”

”They don’t have many activities at the moment, but I like X (Activities co-coordinator) playing the piano.”

“Issues which are raised are not dealt with.”

Some people told us that they liked living at Grace Manor. They said that it had taken them a while to settle in, but that they were now happy living at the home. A relative told us that they had no problems with the home.

People told us that visitors were always welcome.

People told us that they were not aware that they had a plan of care and said that they had not been involved in writing one.

People told us that there were not enough care staff available during the day to support their needs. They said a lack of staffing resulted in: not being able to have a bath when they wanted one; staff being in a rush and not being able to spend time talking to them; and having to wait a long time for staff to be available to take them to the toilet.

People told us that some staff were not gentle with them when they supported them in their care.

People told us that the activities which were provided were good but there weren’t enough of them.

Some people told us that they had a choice of food and drinks whilst other people said that there was not a good choice.

People who had made complaints to the home were not all satisfied with the way that the home had responded.

People told us that their rooms were kept clean, but that they could do with more cleaners so that their rooms were cleaned thoroughly each day.

People told us that they did not like using the communal areas as they were busy and noisy. They said that there were no chairs for visitors.

Some of the people in the home were not able to tell us their views as they had dementia or limited verbal communication. We used a formal way to observe these people. This is called the 'Short Observational Framework for Inspection' (SOFI). This involved observing up to five people for up to an hour. We did this in two areas of the home and recorded their experiences at regular intervals. This included their state of well being, how they interacted with care staff and how they occupied themselves. The findings of our observations are included in this report.