This inspection took place on 29 March and 10 April 2018 and was unannounced. This meant the staff and provider did not know we would be visiting.

Gretton Court is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

Gretton Court accommodates 37 people in one purpose built building. On the day of our inspection there were 37 people using the service. All of the people had nursing care needs and were living with dementia.

The service had a registered manager in place. A registered manager is a person who has registered with CQC to manage the service. Like 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.

Gretton Court was last inspected by CQC in January 2017 and was rated Requires improvement. At the inspection in January 2017 we identified the following breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance). Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions of Safe, Responsive and Well-led to at least good. At this inspection we found improvements had been made in all the areas identified at the previous inspection and the service was now rated Good.

Accidents and incidents were appropriately recorded and investigated. Risk assessments were in place for people who used the service and described potential risks and the safeguards in place to mitigate these risks. The registered manager understood their responsibilities with regard to safeguarding and staff had been trained in safeguarding vulnerable adults.

Medicines were stored safely and securely, and procedures were in place to ensure people received medicines as prescribed.

The home was clean, spacious and suitable for the people who used the service. Appropriate health and safety checks had been carried out.

There were sufficient numbers of staff on duty in order to meet the needs of people who used the service. The provider had an effective recruitment and selection procedure in place and carried out relevant vetting checks when they employed staff. Staff were supported in their role via appropriate training and regular supervisions.

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 were protected from the risk of poor nutrition and staff were aware of people’s nutritional needs. People were supported with their health care needs and care records showed people were supported during visits to and from external health care specialists.

People who used the service and family members were complimentary about the standard of care at Gretton Court. Staff treated people with dignity and respect and helped to maintain people’s independence by encouraging them to care for themselves where possible.

Care records showed that people’s needs were assessed before they started using the service and support plans were written in a person-centred way. Person-centred is about ensuring the person is at the centre of any care or support plans and their individual wishes, needs and choices are taken into account.

Activities were arranged for people who used the service based on their likes and interests, and to help meet their social needs. The service had good links with the local community.

People who used the service and family members were aware of how to make a complaint. The provider had an effective quality assurance process in p

The inspection of Gretton Court commenced on 30 December 2016 and was unannounced.

The inspection was prompted in part by notification of an incident following which a person using the service died. This incident is subject to a criminal investigation and as a result this inspection did not examine the circumstances of the incident.

However, the information shared with CQC about the incident indicated potential concerns about the management of risk. Specifically the risks associated with the use of unsafe equipment, specifically the use of broken bed rails. This inspection examined those risks.

We last inspected Gretton Court in June 2016 and found it was meeting all the legal requirements we inspected against.

Gretton Court is a purpose built single storey nursing home which can accommodate 37 people. There are secured gardens which people who live at Gretton Court can access freely.

At the time of the inspection there were 35 people using the service.

The home had a registered manager at the time of the 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.

We found health and safety checks of equipment and premises were not always completed in line with the providers own requirements. Premises related risk assessments were not signed or dated by the registered manager and not all staff accessed the documents. The control measures within the bed rails risk assessment were not being followed.

Individual risk assessments for bed rails identified the risk of people climbing over the bed rails but there was no information on how this risk was managed. There were inconsistencies in how information related to people’s mobility needs was recorded. Some care plans had not been updated in relation to a change in people’s needs which meant they were at risk of receiving inappropriate or unsafe care.

The concerns we noted during the inspection had not been identified through the provider’s own quality assurance systems. Audits had not been completed in relation to health and safety.

You can see what action we told the provider to take at the back of the full version of the report.

Other audits and quality assurance visits were completed by the care services manager, the director and the proprietors. These had identified some areas for improvement and acknowledged some action had been taken.

Safeguarding concerns, accidents and incidents were recorded and investigated. Lessons learnt were evident.

There were enough staff to meet people’s needs and safe recruitment practices were followed.

Medicines were managed safely, audits were completed and one of the nurses had a lead role as the medicines champion.

Staff training was up to date and where refresher training was needed this had been booked. Supervisions and appraisals were completed routinely and staff told us they felt well supported by the staff team and the management team.

Deprivation of Liberty Safeguards (DoLS) authorisations were in place and care plans provided detail to staff on any deprivations, such as people being unable to access the community without support. Staff understood the need to support people to make their own decisions but if this was not possible they made decisions in people’s best interest.

There were warm, caring and compassionate relationships observed between staff and people. People often instigated affection with staff offering cuddles and hands to hold which was accepted and reciprocated in a respectful and appropriate manner.

Care plans were in place and reviewed each month. Care records included information about people’s life history which had often been completed by family members.

We observed staff were engaged in activities with people

This inspection took place on 6 and 8 June 2016. The first day was unannounced. The second day was announced. We last inspected Gretton Court on 20 January 2014 and found it was meeting all legal requirements we inspected against.

Gretton Court is a purpose built single storey nursing home which can accommodate 37 people. There are secured gardens which people who live at Gretton Court can access freely.

At the time of the inspection there were 37 people using the service.

A registered manager was registered with the Care Quality Commission at the time of the 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.

People's relatives told us they thought their family members were safe living at Gretton Court. One relative said, “[Family member] is very safe, you can’t fault the care here, people are well looked after.” Staff were knowledgeable about safeguarding people from harm and risk assessments were in place to manage risks to people’s health, wellbeing and safety.

Medicines were managed in a safe way. Person centred care plans and as and when required medicine sheets detailed how people liked to take their medicine. Appropriate best interest decisions had been recorded for people who took their medicine covertly. This means their medicines were hidden in food or drinks to support them to take it appropriately.

Accidents and incidents were recorded and investigated with lessons learnt being documented and acted upon.

The registered manager told us they assessed each person living at Gretton Court as having high needs. This meant the service was permanently staff to the maximum level indicated by the dependency tool. This gave staff the time they needed to support people in an unhurried manner. They also had time to spend with people one to one chatting and offering comfort if they were upset or distressed. Staff treated people with care and respect. We observed the use of appropriate touch to comfort people, which was often reciprocated and initiated by people.

Staff were well trained and told us they were well supported. The nursing staff respected and valued how well the care staff knew the people living at Gretton Court.

Care plans were person centred and contained detail in relation to the communication needs of people. One care plan lacked detail of how to support and care for the person, and one lacked up to date information from a dietitian. Other care plans were detailed and specific to the needs of the person.

Activities were arranged on a four weekly rota, and included outdoor and indoor activities. A weekend activity box was available for care staff to use when the activities co-ordinator was not at work.

All the people living at Gretton Court had authorised Deprivation of Liberty Safeguards (DoLS) in place and staff understood the restrictions this placed on people. There was importance placed upon people having as much freedom and fresh air as they wanted, so there were no locked doors within the service and people had free access to the secure gardens. The registered manager said, “The use of prn [as and when required medicines] has reduced since people had free access to the garden, it gives people the space and fresh air to calm and walk as they need to.”

Staff and visitors told us the registered manager was approachable. We observed they were visible to people and knew people and staff. There was a definite team spirit and staff worked together to provide good quality care for people. There were a range of quality assurance processes in place to assess, monitor and improve the quality of the service, including audits completed by the registered manager, the care services manager and the board of trustees.

We found that the arrangement in place to seek people's consent for treatment had improved significantly. Staff were clear about the legal arrangement in place for people when they lacked the capacity to make complex decisions such as who had lasting power of attorney in place and whether this was for people's finances or care welfare. There was detailed information in care plans about how to assist people with decision making.

The service had a complaint process. People told us they found the management team to be approachable and had no concerns about making complaints or raising concerns.

We found that the standard of record keeping in the service had improved. Records were accurate and fit for purpose thus people who used the service were protected from the risks of receiving unsafe or inappropriate care and treatment.

We used a special way of observing people who lived at Gretton Court. It enabled us to have a better understanding of their experiences. We carried out observations because some people’s health conditions meant they were often unable to recall recent events, understand our questions or have meaningful conversations.

We spoke with relatives of people who used the service. They told us they were happy with the care and support their relatives received. They also told us that they thought there were enough staff employed by the service to meet people’s needs.

We found that people who lived at the home received treatment and support that met their needs. We also found that there were enough staff employed by the service to meet people’s needs.

We found arrangements to seek people's consent for treatment needed to improve. The manager was unsure about the legal arrangements in place for people when they lacked the capacity to make complex decisions, such as who had lasting power of attorney in place and whether this was for finances or care and welfare.

Although the service had a complaint process, we received mixed information about it. Some people told us that they felt able to speak with the manager and raise a concern however others said they would be reluctant to complain for fear of repercussions.

Records were not always accurate or fit for purpose and did not protect people who used the service from the risks of receiving unsafe or inappropriate care.

We carried out this inspection because the last time we inspected Gretton Court we found they were failing to meet two essential standards. At this inspection we looked at these two standards to ensure improvements had been made and the standards were being met.

We found care planning had been carried out and whenever possible relatives had been involved. Risk assessments had been undertaken and staff appeared to be aware of people’s needs and supported them appropriately.

We carried out observations of staff and people who used the service and found people who lived at Gretton Court looked content and well cared for. They were wearing clean clothes and were well groomed. There were activities taking place that people could join in with. We saw people had a good rapport with each other and staff were aware of and attentive to people's needs.

Staff were able to attend training sessions and were up to date with their mandatory training. Additional training applicable to the service such as dementia awareness and challenging behaviour were also available.

A new staff supervision system was being implemented and nursing staff were due to undergo training to enable them to carry out supervisions with care staff. Supervisions were up to date although some care staff were due supervision sessions in the coming weeks. Nurses whose files we looked at also needed to have some individual supervision sessions to accompany the group sessions they had attended recently.

Because people with dementia are not always able to tell us about their experiences or express their opinions, we used a formal way to observe people’s experiences of living in the home and their interactions with each other and with staff. We call this the Short Observational Framework for Inspection (SOFI).

Throughout our observations we saw people being treated with dignity, respect and courtesy most of the time. We saw that staff were able to communicate with people who used verbal and non verbal communication. Staff smiled at people and asked them how they were. On most occasions they also waited for people to respond and then acted according to the response.

During our observations we saw that staff and the activities co-ordinators engaged with people and tried to encourage them to take part in activities. There were different activities available for people and those who joined in appeared to be enjoying themselves. We also saw that staff explained to people what was happening to them and were discreet when helping people with personal care needs. We saw that the majority of staff had a good rapport with the people they provided care for and knew them well.

We spoke with two relatives about Gretton Court. They were happy with the care their family members received although one person told us that sometimes some members of staff have, “Off days, but on they whole they do their best”. They also told us that sometimes it was difficult to have a private conversation because staff, “Ear wigged and were sometimes indiscreet about things they over heard”. We did note that there were private areas within Gretton Court where people and their visitors could go if they wished for privacy.