This unannounced inspection took place on 7 and 8 August 2018.

This service has a dual registration which means there are two registered providers jointly managing the regulated activities at this one location. The service is subject to one inspection visit however, the report is published on our website twice, under each provider.

Gracewell of Salisbury is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The care home accommodates 63 people in one adapted building. At the time of our inspection 58 people were residing at the home. The service is in the city of Salisbury. Accommodation is arranged over three floors which are accessed via a lift. All rooms are en-suite and there are landscaped gardens.

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 unannounced focused inspection in August 2016 we found the service was not meeting legal requirements. We found concerns relating to medicines management and records relating to incidents and accidents. At this inspection we found the necessary improvements had been made and we rated the service ‘Good’ overall.

Medicines were managed safely. Where appropriate people were supported to manage their own medicines. We observed staff administering medicines and found their practice to be safe. Staff had received training on medicines administration and had their practice observed to check for competence.

Accidents and incidents had been recorded in detail and action taken to minimise the risk of re-occurrence. There were opportunities for staff to discuss incidents and use reflection to learn any lessons. Risks had been identified and safety measures put in place to keep people safe from avoidable harm. All risk assessments were reviewed regularly. Care and support plans contained sufficient detail to support the staff to deliver personalised care.

The service had improved systems in place following falls. If people sustained a fall they were assessed by a nurse. If further medical advice or treatment was needed, this was sought. There were clear records of actions taken, and people were re-assessed as a precaution. Handover information was clear and up to date.

There were daily head of department meetings, regular team and ‘resident meetings’, where people and staff could share ideas. Minutes were kept and reflected on to make sure actions raised were closed. The service sought the views of people and their relatives, to try to improve the care and support.

Staff were recruited safely, and the required pre-employment checks had been completed. There were sufficient staff deployed to meet people’s needs consistently. Gracewell of Salisbury had a consistent and experienced staff team who knew people’s needs well.

Staff understood the different types of abuse and how to report any concerns. Training had been provided in a variety of topics and staff told us they felt well supported. Supervision was available, where staff could discuss any concerns, training needs or development opportunities.

The service was clean and free from unpleasant odours. We observed the staff used appropriate infection prevention and control good practice. The premises and equipment was maintained and serviced when required.

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’s needs were assessed and where needed, ref

Gracewell of Salisbury is a purpose-built care home with nursing for up to 63 people, some of whom may be living with dementia. The service also provided care for people staying short term for example, people who were having rehabilitation following an operation. At the time of this inspection 46 people were using the service. The inspection took place on 23, 24 and 25 August 2016. This was an unannounced inspection.

We carried out an unannounced comprehensive inspection of this service on 18 March 2016. After that inspection we received concerns in relation to the management of incidents and accidents and medicines. As a result we undertook a focused inspection to look into those concerns. This report covers our findings in relation to those concerns. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Gracewell of Salisbury on our website at www.cqc.org.uk

There was a registered manager in post when we inspected the service. 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 registered manager was present and approachable throughout our inspection. Staff and people who used the service told us the registered manager was available if they needed to speak with her and had confidence in her abilities to manage the service.

Medicines were not always managed appropriately in the home. This included staff knowledge for medicines taken as required, for thickening fluid and the recording for people who needed their medicines covertly.

The home had sufficient levels of staff in place; however staff were not always deployed in an efficient way to ensure people were kept safe. People we spoke with described the pressure staff were under which led to them experiencing rushed care. Comments included “I am concerned by the staff that are under great pressure, I listen and hear them talking among themselves, nothing indiscrete”, “I am not sure if residents understand why they are having to wait, especially after a meal, there is pressure to get everyone back to their rooms and they can’t do that”.

People had experienced very high numbers of falls within the home. Falls were also not always sufficiently followed up in order for corrective action and risk assessments to be put in place. Monitoring forms and recording following accidents and incidents were not consistently completed which made it hard to ascertain a person’s accurate condition. Staff’s knowledge about people who had experienced falls or had injuries was not always accurate or effectively communicated within the staff team.

Staff had all received safeguarding training, and were aware of their responsibilities in reporting concerns, and the concerns of those they supported. Staff were able to describe to us the actions they would take if they suspected someone may be at harm of abuse.

Communication and participation in the development of the home was encouraged and feedback was considered and where appropriate acted upon. Relatives were welcomed in the home and involved in their loved one's care.

The registered manager was approachable and available for people to see. People, their relatives and staff felt confident that the home was well managed.

The registered manager had developed organised systems in relation to the management of the home. Quality monitoring checks and analysis of incidents were in place and used to further improve the service.

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 the report.

Gracewell of Salisbury provides accommodation and nursing care for up to 63 older people. At the time of our inspection 45 people were living at the home. The home was last inspected in April 2014 and was found to be meeting all of the standards assessed.

This inspection took place on 15 March 2016 and was unannounced. We returned on 18 March 2016 to complete the inspection.

There was a registered manager in post at the service. 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 and associated Regulations about how the service is run.

People who use the service and their relatives were positive about the care they received and praised the quality of the staff and management. Comments from people included, “The nurses and carers are always there when you need them”, “I feel very safe here, there’s nothing to worry about” and “The staff treat me well and I feel safe”. A relative told us, “The nurses and carers are always there when you need them”.

People told us they felt safe when receiving care and were involved in developing and reviewing their care plans. Systems were in place to protect people from abuse and harm and staff knew their responsibilities.

Staff understood the needs of the people they were providing care for. People told us staff provided care with kindness and compassion.

Staff were appropriately trained and skilled. They received a thorough induction when they started working at the home. They demonstrated a good understanding of their role and responsibilities. Staff had completed training to ensure the care and support provided to people was safe and effective to meet their needs.

The service was responsive to people’s needs and wishes. People had regular group and individual meetings to provide feedback about their care and there was an effective complaints procedure. Comments from people included, “They ask lots of questions about what we want and how we want it” and “I would speak to one of the nurses if I had a problem, they would help to resolve it”.

The provider regularly assessed and monitored the quality of care provided at Gracewell of Salisbury. People and their relatives were encouraged to express their views on the service and this was used to make improvements.

This inspection took place over one day. It was performed by one inspector. During the inspection, we spoke with eleven people who lived in the home, one visitor and nine members of staff, including ancillary staff, care workers, registered nurses and the home manager. We observed care given to people in their own rooms and sitting and dining rooms. We inspected the facilities in the home, and looked at records. The home opened in June 2013. At the time of this inspection, 31 of the 63 beds were occupied. Only two of the three floors of the home were open.

We considered our inspection findings to answer questions we always ask;

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 would like to see the evidence supporting our summary please read the full report.

Is the service caring?

One person told us “I think it’s very good.” A person’s visitor reported they felt they were “so lucky” their relative was in this home.

We observed a person rang their call bell by mistake. The person sounded anxious that they had caused a false alarm. The member of staff who answered the bell was kindly and understanding towards the person.

In a sitting area a member of staff observed a person’s foot had come off their wheelchair foot plate. They asked the person’s permission to put their foot back on back on the foot-plate. The person said they wanted a drink first. The member of staff respected this. When the person had finished drinking, they asked their permission to put their foot back on the foot-plate of their wheelchair. They explained what they were doing all the time they helped the person and did not rush them in any way.

Is the service responsive?

One person we met with told us they had actively chosen to live at Salisbury Manor Care Home, with support from their family. This had included making visits before they made up their mind to be admitted.

A person told us “they’re letting me eat all my meals in here” [their own room]. They reported “it’s much better for me.” A person informed us about their choices at mealtimes. They said if they did not like what was offered, they would tell staff who would get what they wanted to eat “within reason.” They said “they’re very reasonable like that.”

A person reported “we aren’t locked in” and said they knew the code on the number lock to get out of the home.

People reported management was approachable if they wished to raise issues. One person said if they had a problem they would “go upstairs to management.” A visitor told us they went to see the manager or deputy if they had concerns.

Is the service safe?

People told us they felt safe in the home. One person said “there’s always somebody here,” about the availability of staff.

We observed two members of staff supporting a person who had difficulties with moving. We saw they correctly and safely used moving and handling equipment.

The home’s main service areas were secured to ensure people could not access them, so as to prevent them from putting themselves at risk. One part of the external area of the home needed building works. This was fully and securely screened off, to ensure the safety of people, staff and others.

The provider had an addressable alarm system which meant staff could quickly and easily attend to a person if they rang their call or emergency bell.

The provider had safe systems for recruitment of staff, which ensured only staff who were suitable for their role were appointed.

The CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. One application had been submitted from this home. The local DoLS team assessed safeguards were not needed for this person. All of the staff we spoke with were aware of the importance of these safeguards.

Is the service effective?

A visitor reported “the care is very good,” saying that staff “go out of way to support” the person. A person described how they had been taken very ill one lunch-time. They said how quickly staff had responded to them. We observed an emergency bell was rung. Staff responded promptly and in a calm way, when this happened.

One of the people we met with was living with dementia. They showed some signs of anxious behaviour. A registered nurse told us in detail about the person’s needs and how they supported them. The person’s records showed they were experiencing fewer incidents of anxious behaviours as they became familiarised to the home.

One of the people had a wound. They had clear records about the wound, which fully reflected what a registered nurse told us. A person had a urinary catheter in place. Their records also showed the catheter was being regularly changed in accordance with manufacturer’s instructions.

One of the people we met with had been admitted the previous day. We saw the home had already drawn up relevant initial base-line records in relation to the person’s needs. This included body maps relating to the person’s skin marking.

Is the service well led?

Staff told us the manager took relevant actions when needed. This included the manager making sure that agency staff did not work in the home again if they had not appropriately supported people and staff.

The manager reported they met with each person living in the home every day, to hear their comments and review care provided. People’s files were regularly audited to ensure they were properly maintained and included all necessary information.

The provider regularly audited other areas, including medicines, accidents/incidents and complaints to identify issues for action. Audits included unannounced visits by the provider.

The home manager told us they had a brief heads of department meeting each morning, so they were aware of issues currently affecting the home. They also held staff meetings and reviewed feedback arising from staff supervisions.

The manager reported the provider had ensured a planned, staged approach to the admission of people to the home. This ensured the home only admitted people when they were able to meet their needs.