About the service:

Hodge Hill Grange is a care home that provides nursing and personal care for up to 52 people within one large adapted building, which is divided into three units. It specialises in the care of people living with dementia and older people requiring general nursing care. At the time of our inspection, 43 people were living at the home.

People's experience of using this service:

• The administration of people’s topical medicines was not managed as effectively.

• People’s relatives and staff continued to express mixed views on staffing levels at the service.

• Staff training needs had not been consistently monitored and addressed.

• The formal mental capacity assessments we reviewed were not decision-specific, and contradictory information had been recorded about people’s mental capacity.

• The provider followed safe recruitment practices to ensure prospective staff were suitable to work with people.

• The provider had systems and procedures in place to manage the risks associated with the premises, care equipment in use and people’s individual needs.

• Staff understood the need to report any abuse concerns without delay.

• The provider took steps to protect people, staff and visitors from the risk of infections.

• New permanent and agency staff received an induction to help them understand the service and their roles.

• People’s needs and wishes were assessed before they moved into the home, to form the basis of initial care planning and risk assessment.

• People were encouraged and supported to make choices about what they ate and drank. Any complex needs or risk associated with their eating and drinking were assessed and managed.

• The provider had taken some measures to create a dementia-friendly environment, and had plans in place to further adapt the home to people’s needs.

• Staff and management worked with a range of healthcare professionals to ensure people’s health needs were monitored and met.

• Staff adopted a kind and compassionate approach to their work, and had taken the time to get to know people well.

• Staff recognised the need to promote people’s equality and value their diversity.

• People’s care plans were individualised and promoted a person-centred approach.

• People had the opportunity to participate in social and recreational activities, and the registered manager had plans to develop this aspect of the service.

• The people and relatives we spoke with were clear how to raise concerns and complaints about the service.

• People’s needs and choices regarding their end of life care were assessed and addressed.

• The provider had quality assurance systems and processes in place to monitor the quality and safety of people’s care. However, these had not enabled them to address the shortfalls in quality we identified during our inspection.

• People’s relatives and staff spoke positively about their relationship with the registered manager, who they found approachable and willing to listen.

We found the service met the requirements for 'Good' in two areas, and 'Requires improvement' in three other areas. For more details, please see the full report which is on the CQC website at www.cqc.org.uk.

Rating at last inspection: At the last comprehensive inspection, the service was rated as 'Requires improvement' (inspection report published on 5 June 2017). At this inspection, the overall rating of the service remained the same.

Why we inspected: This was a planned inspection based on the service's previous rating.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our inspection programme. If any information of concern is received, we may inspect sooner.

This inspection took place on 22 and 23 March 2017 and was an unannounced comprehensive inspection. The location was last inspected on 17 May 2016 and was rated as ‘Good’ overall. We brought forward our planned inspection due to an increased number of concerns about the service, since our last inspection.

Hodge Hill Grange is a nursing home and is registered to provide accommodation for up to 54 people who require nursing or personal care. At the time of our inspection there were 46 people living at the home.

There was no registered manager in post at the time of our 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 were not always kept safe. Staff were not trained and supported so that they had the knowledge and skills they required to enable them to care for people in a way that met their individual needs and preferences. Staff had received training and understood the different types of abuse and knew what action they would take if they thought a person was at risk of harm. Staff had been safely recruited and relatives felt that staff demonstrated the appropriate skills and knowledge to provide good care and support.

Staff were not always responsive to people’s individual care and support needs, meaning they did not always receive the care and support they needed in a timely manner.

There was a lack of meaningful and stimulating person specific activities for people to take part in and people did not get the opportunity to take part in recreational activities that they enjoyed .

The provider’s quality assurance and audit systems were not always effective when in place to monitoring the care and support people received, to ensure that the quality of service provided remained consistent and effective.

People’s individual life style choices and life history was not well documented in their care plans so there was a risk that staff don’t have the information needed to provide person centred care .

People’s medicines were managed and administered safely so that people received their medicines as prescribed.

People were encouraged to make choices and were involved in the care and support they received. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. Staff were respectful of people’s diverse needs and the importance of promoting equality.

Staff were caring and treated people with dignity and respect and their independence was promoted. People and their relatives felt they could speak with the provider about their worries or concerns and were confident that they would be listened to and have their concerns addressed.

This inspection took place on 17 May 2016 and was an unannounced comprehensive rating inspection.

Hodge Hill Grange is registered to provide accommodation for up to 54 older people who require nursing and personal care. On the day of our inspection there was extensive renovation work taking place on the ground floor of the home, which meant that fewer people were living at the location at this time. There were 39 people living at the location, many of whom had care and support needs relating to dementia.

At the time of our inspection there was a registered manager in post. The registered manager was new to the provider and had been in post for three months. 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 unavailable on the day of the inspection, therefore we were assisted by the deputy manager.

People were safe and secure because risks had been assessed and managed appropriately. Staff were able to identify possible abuse and take actions to alert the appropriate professionals so that they could be protected.

People safely received their medicines as prescribed to them by staff who were trained appropriately.

Staff had been recruited appropriately and had received relevant training so that they were able to support people with their individual needs.

People were supported to have food that they enjoyed and meal times were flexible to meet people’s needs.

Staff understood when the legal requirements of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards (DoLS) should be followed.

People were supported to stay healthy and had access to health care professionals as required. They were treated with kindness and compassion but there was inconsistency of good communication and interaction between staff and the people living at the location.

People’s right to privacy was promoted and people were encouraged to be as independent as possible.

People received care from staff that knew them well and benefitted from opportunities to take part in activities that they enjoyed. The provider was in the process of developing a wider variety of activities, having recently recruited a new activities coordinator.

People’s care and support needs were not always responded to in a timely manner.

The provider had management systems in place to audit, assess and monitor the quality of the service provided. The provider used feedback from audits to inform future service provision.

We used a number of different methods to help us understand the experiences of people using the service, because the people using the service had complex needs which meant they were not able to tell us their experiences

We found effective systems were in place that ensured medicines were managed safely. Staff were able to assure people that their medicines were stored safely and people were found to be receiving their medicines in accordance with the prescriber’s advice.

During our previous inspection in August 2013, we identified that the registered provider was not meeting some of the requirements. We returned in November to inspect to see if actions the provider had told us about had been implemented. We found that planned improvements had not been made by the provider. As a consequence of the continued non-compliance with the management of medicines and the assessing and monitoring the quality of service provision warning notices, dated 13 December 2013 was issued to the provider for Regulations 10 and 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. The warning notice provided details as to how we had judged the service to be non-compliant and set a requirement for the service to be compliant with this regulation by the 10 January 2014. At this inspection we followed up the requirements set out in the warning notices and the compliance action set for the care and welfare of people that use the service.

We found some improvements had been made to people's care and welfare. However, not all planned improvement had yet been implemented.

We found that the requirements set out in the warning notices had not been met. Systems for the management of medicines were not effective or robust. We found some of the provider's systems for quality assurance were not effective or robust.

We found the service had poor systems in place to ensure the safe management of medicines. We found poor ordering systems had left people without medicines to take and poor administration record meant that we were unable to see if people were having their medicines administered as prescribed.

During our inspection of this service in August 2013 we found non-compliance with three outcome areas; care and welfare of people, management of medicines and the assessing and monitoring of the quality of service provision. We also found that there was inadequate overall scrutiny from the registered person to give assurance that the service was being run as it should have been. We carried out this inspection to find out if improvements had been made. We found that planned improvement had not been made.

We were told that the previous manager had left and a relief manager had started work at the home in November 2013.

No one knew we would be inspecting. We were told that 52 people lived at the home on the day of our inspection. During our inspection we spoke with eight people who lived there. We observed the experiences of some other people that lived there that were not able to verbally communicate with us. We also spoke with eight people's relatives, five care staff and one other staff member, the new relief manager, the area manager and another local home manager.

We found that the care and welfare needs of people that lived there were ot always met. Improvement was needed. One person told us, "Some staff are kind and help me." Another person told us, "The food is not very good and there is nothing to do. It is boring."

We saw that the system for ordering people’s medication was not robust. We also found that people were not always protected from the risks associated with the unsafe use and management of medicines.

We found that systems of audit to ensure that the service was being run in the best interests of the people who lived there were not robust. Planned improvement had not been implemented.

On the day of our inspection we were told that 47 people were living at Hodge Hill Grange. During our inspection, we looked at four sets of care records and spoke with the manager and deputy manager. We spoke with one nurse, six care staff and two other staff members, 13 people using the service and 10 relatives of people.

During this inspection, we looked to see if improvement had been made since our previous inspection (April 2013).

Most people were involved in their care and privacy and dignity were respected.

Care plans were personalised and risk assessments were in place so that staff had the information they needed to meet people's identified needs. We saw some people's needs were not met in a timely way and people had to wait. One person told us, "I always have to wait for staff to help me."

Arrangements were in place to ensure that people were safeguarded against the risk of harm.

We found that arrangements in place for obtaining people's medication were not effective.

Staff felt supported in their job roles. One staff member told us, "I enjoy working with the older people at the home."

We saw systems in place to audit and monitor the quality of the service being provided but these were not effective.

This inspection was part of an inspection programme to assess whether older people living in care homes are treated with dignity and respect and whether their nutritional needs are met. The inspection team was led by one of two CQC inspectors and was joined by a practising professional and an expert by experience. This is a person who has experience of using services and can therefore provide their perspective on the quality of service provided at the home.

There were forty four people using the service at the time of our visit. We spoke with at least ten of these people and the staff that were supporting them. We spoke with five relatives that were visiting the home. We arrived at the home unannounced.

People told us what it was like to live at this home and described how they were treated by staff and of their involvement in making choices about their care. The findings of our inspection showed that people were involved in making some decisions about how they spent their time.

People told us about the quality and choice of food and drink available. People had mixed views about this. The findings of our inspection showed that during meal times, people did not always receive support from staff in a timely manner. People using the service told us “We don’t know what food we’re eating” and “Sometimes the food’s rubbish, sometimes you can’t even cut the meat.”

People told us that most staff supported them in a respectful and sensitive manner. The findings of our inspection showed that this was not always the case. Agency staff were covering staff vacancies. This meant that people were not always supported by staff who had a good understanding of their individual care needs and preferences. This may have resulted in people not receiving care and support in the way that they needed or preferred. A person using the service told us “There are lots of agency staff, they don’t know people.”

People using the service and their relatives had mixed views about whether they knew how to raise concerns. They told us “If I don’t like it, I tell them” and “I am not aware of the complaints procedure.”

We visited Hodge Hill Grange and carried out an inspection there. During our previous inspections in 2013 and January 2014 we found that the provider was not meeting the requirements of the regulations. We took enforcement action. During this inspection we looked to see if improvement had been made. We found that a lot of improvement had been made but there was a need for further improvement.

We looked at information to help us gather evidence about the quality of the provider’s care and support to people that lived there. On the day of our inspection, the manager told us that 30 people lived there.

We spoke with the manager, area manager and quality assurance manager. We also spoke with nursing and care staff on duty and other staff members such as the chef and the activities organiser. We spoke with 11 people that lived there and observed other people. We later spoke with 14 relatives. We also looked at records. Our conversations with people helped us to answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? and, Is the service well led?

Below is a summary of what we found.

Detailed evidence supporting our summary can be read in our full report.

Is the service safe?

All of the people spoken with told us that they felt safe living at the home. One person told us, “I feel safe here. Things have improved a lot over the last few months.” All of the relatives spoken with confirmed to us that they felt that their family member was safe there. One relative told us, “I have no concerns. My family member is safe there.”

There was a system in place to record accidents and incidents. Staff spoken with showed that they were aware of the reporting system. We saw that nine accidents and incidents were recorded for March and fourteen for April 2014. We saw that the provider had taken appropriate action to record these and take the appropriate steps to minimise the risk of reoccurrence.

There was a system in place to handle concerns and complaints. The manager told us that two complaints had been received by the provider from people that lived there or their relatives since our last inspection in January 2014. However, a few relatives told us of concerns and complaints that we saw had not been recorded or resolved.

The manager told us that several new staff had commenced employment at the home since our last inspection. We saw that staff files contained the required pre-employment checks. This meant that the provider ensured that people employed were suitable to work with vulnerable adults.

As part of our inspection we asked the registered manager about how they implemented the Mental Capacity Act 2005 Deprivation of Liberty Safeguards (DOLS). They told us that they would make the appropriate referrals for people if needed.

Effective systems were not fully in place to ensure that medicines were managed safely. We saw that people did not always receive their medicines in accordance with the prescriber’s advice. A compliance action has been set. This means that the provider will need to send us an action plan telling us how they will make further improvements.

Is the service effective?

We saw that the provider's information guide was displayed in the home and gave people information about the service.

We saw that information was displayed about activities that were planned. We also saw that a newsletter was available to people and their relatives.

All of the people we spoke with told us and we found that meals were appetizing and hot when served. One person told us, “The food has improved.”

Is the service caring?

Most people we spoke with told us that they thought most of the staff were kind and caring. One relative told us, “The care has improved overall. Although it could improve a bit more when the home manager is not there, with just the little things like making sure people have their hearing aid or glasses.”

People that lived there and their relatives were asked for feedback about the service. Resident and relative meetings took place so that feedback could be gathered.

Is the service responsive?

We saw that ‘resident meetings’ and ‘relative meetings’ took place. We saw examples of how the provider had responded to issues raised. For example people that lived there wanted to go on day trips. We saw that action was underway to take on a few relative volunteer mini-bus drivers so that day trips could be offered to people. This meant that the service was responsive. However, we also observed that one request made by people was not being met during our inspection. One person told us, “It depends which staff are on duty.” This meant that there was an inconsistent staff approach in responding to people’s requests.

Most relatives spoken with told us they had no concerns or complaints. Most relatives told us that they felt the service had improved. One relative told us, “I now feel that I could recommend the home. Things have improved overall.” However, a few relatives told us that concerns or complaints made by them to staff had not been responded to.

Is the service well led?

On 6 February 2014 we served a fixed penalty notice to the provider, HC One, for failing to have a registered manager in place at Hodge Hill Grange. A fine of £4,000 was paid. In May 2014 an application was submitted by the manager to become registered with us.

All of the staff told us that they felt supported in the job role by the manager. One staff member told us, “The manager is approachable. There is better communication now and things have improved.” This meant that staff were well-led.

We saw documented evidence that showed that the provider worked with other

health care professionals and made referrals for advice and guidance when needed.

The service had a quality assurance system. Records looked at showed that audits took place. We also saw that audits had action plans and that actions were implemented.