The inspection visit took place on 9 November 2016 and was unannounced.

Kirby Grange is a residential care home providing accommodation for up to 31 people who require personal or nursing care. The service does not directly provide nursing care, but arranges for nurses to visit the home. Accommodation is on two floors that are connected by stairs and a lift. There is a communal dining area and three communal lounges, one of which was undergoing renovation at the time of our inspection. At the time of our inspection 25 people used the service.

A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 the time of our inspection on 18 November 2015 the service had not had a registered manager for over 12 months. We required the provider to take action to have a registered manager. At this inspection a manager was awaiting the outcome of their application to the Care Quality Commission to be registered manager. They were registered on 24 November 2016.

People who used the service were safe. They were supported and cared for by staff that had been employed under the provider's recruitment procedures. These ensured as far as possible that only staff that were suited to work at the service were employed. Staff understood and carried out their responsibilities for protecting people from abuse and avoidable harm.

People’s care plans included risk assessments of activities associated with their personal care routines. The risk assessments provided information for care workers that enabled them to support people safely but without restricting their independence.

Enough suitably skilled and knowledgeable staff were deployed to meet the needs of the people using the service. The manager decided staffing levels based on the needs of people who used the service. The manager was involved in 'hands-on' support and care of people who used the service as a means of maintaining their knowledge of people’s needs.

People were supported to receive the medicines by staff who were trained in medicines management. Arrangements for ordering, storing, disposing and administration of medicines were safe. The manager had made this one of their priorities after they joined the service.

Care workers were supported through training, supervision and appraisal. Staff told us that they felt supported..

The manager understood their responsibilities under the Mental Capacity Act (MCA) 2015. Staff had awareness of the MCA. They understood they could provide care and support only if a person consented to it and if the proper safeguards were put in place to protect their rights. There were people at Kirby Grange who were being cared for under Deprivation of Liberty Safeguards which meant their rights were protected.

Staff understood the importance people having healthy diets and having enough to eat and drink. They supported people at meal times to have their meals. They also supported people to access health services when they needed them.

People and their relatives were involved in decisions about their care and support. They received the information they needed about the service and about their care and support.

People told us they were treated with dignity and respect. The manager was a ‘dignity champion’ and they promoted values of compassion and kindness in the service.

People contributed to the assessment of their needs and to reviews of their care plans. Their care plans were centred on their individual needs. People knew how to raise concerns if they felt they had to and they were confident they would be taken seriously by the provider. When people expressed preferences about their care and support these were acted upon by the manager.

The service h

We made an unannounced inspection of the service on 18 November 2015.

At our previous inspection in July 2014 we identified two breaches of regulation. These concerned management of medicines and supporting staff through training, supervision and appraisal. The provider had made improvements to meet the relevant requirements, but at this inspection we identified that aspects of support for staff had not been sustained although the provider had identified this and begun to address it before our inspection.

Kirby Grange is a residential care home providing care for up to 31 older people. Accommodation is on two floors. The home has two large communal lounges, a dining area and an enclosed garden. At the time of our inspection 23 people were using the service.

It is a condition of registration that the service has a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider. The service last had a registered manager in July 2014. A person has been managing the service since then but they had not, at the time of this inspection, applied to be a registered manager. This left the service without a registered manager for 16 months. This was a breach of a condition of registration.

Although people using the service told us they felt safe we saw evidence to the contrary. A person’s care plan did not have any risk assessments despite there being a clear need for them. Action to carry our risk assessments was taken after we brought the matter to the manager’s attention. Aspects of the environment of the home presented risks of harm to people. Window restrictors were `home-made’ and were ineffective. That was evidenced by the fact that shortly before our inspection a person had tried to leave the home through a window. An equipment storage area and an area of the home undergoing renovation were not secure and a utility room was unlocked. All of these matters were addressed after we brought them to the attention of the manager.

People’s rooms had pressure sensors which were switched off during the day which meant a person could have had an undetected fall in their room. Call alarms in people’s rooms were switched off during periods of electrical work which affected how they could summon help at those times.

Enough staff were deployed to meet people’s needs. The provider operated effective recruitment procedures.

We found minor recording errors in the services controlled drugs register. During a medicines round a person was left alone with their medicines for 10 minutes.

People using the service and relatives felt staff were adequately trained. Staff training and supervision had fallen behind but this had begun to be addressed by the provider before our inspection.

Staff communicated effectively with people most of the time but communications were hindered because a lot of people were hard of hearing. We have made a recommendation to the provider about this.

There were reasonable doubts about whether a person had mental capacity to make decision about their care. No assessment had been made under the Mental Capacity Act 2005 and no consideration had been made about whether a Deprivation of Liberty Safeguards authorisation was required. This was addressed after we brought the matter to the attention of the manager.

Not all staff we spoke with had a clear awareness of the relevance of the MCA to their role.

People using the service told us they enjoyed their meals. They had a choice of meals, but less choice about how meals were served.

No action was recorded in respect of a person who had lost 10% of their body weight in nine weeks until we brought the matter to the attention of the manager.

Staff were caring and compassionate but we saw two instances of staff being abrupt.

People or their representatives had not been given their private mail for over two we

At our inspection we gathered evidence that helped answer our five questions. Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with two people who used the service, two relatives, four staff and from looking at records.

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

Is the service safe?

People we spoke with told us they felt safe living at the home. One person told us, "I feel safe here. I'm comfortable in my room. When I've used the call alarm they [staff] have always come quickly." Another person told us, "I'm safe here. I have a very pleasant room. I have my own things in it. I'm comfortable and safe." They added, "I've never seen anything that worried me. I know how I could make a complaint. If I had anything to say, I'd say it."

A relative told us, "I visit the home most days. It's safe here."

We observed how staff behaved with people. Staff protected people's dignity and spoke respectfully with people.

All staff we spoke with knew how to recognise and report signs of abuse. They were able to name the forms of abuse recognised in the Health and Social Care Act 2010. Staff knew how to identify and report concerns about people's safety internally within

the home but they told us they had lost the confidence to do so. Before our inspection we had received concerns from staff about the management of the home. Before and during our inspection, the local authority social services safeguarding team were investigating information they had received from staff and ourselves about the service.

A person who used the service told us, "It sometimes feels as if not enough staff are on duty, but I've never felt unsafe when it's been like that." Another person told us, "The girls [staff] are overworked." Staff we spoke with gave different feedback about their working hours. One told us they felt compelled to work long hours; another told us they wanted to. Most days the manager, a senior care worker and three care workers were on duty. At busy times of the day they were assisted by two other staff who had been trained to carry out care duties.

Staff we spoke with had only a basic awareness of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). This is legislation that protects vulnerable people who are or may become deprived of their liberty through the use of restraint, restriction of movement and control.

Is the service effective?

Care plans included details of people's needs and information about how they were supported with their needs. People who used the service told us that they had been well cared for and supported. One person told us, "The care is very good. If I ask for anything the staff do it." Another person told us, "When I first came here I could hardly sit up but I can now because the staff have helped me." A relative was complimentary about the care provided. They told us, "It's a good home. The residents only need to ask and it's provided."

Until a few days before our inspection senior care workers had given one person insulin injections without proper training Staff we spoke with told us that they had not been supported through effective supervision or appraisal. Most staff we spoke with told us they had not been properly supported by the registered manager. One told us they had been placed into a senior position well before they felt ready for it.

People who used the service were complimentary about the staff and the care they received. People told us they felt comfortable about discussing their needs with staff.

Care workers we spoke with told us that they regularly referred to people's care plans.

Is the service caring?

People told us they were well cared for. One person told us, "The staff have always been nice to me." A relative told us, "It's a very friendly atmosphere. My [spouse] gets all the care they require." We saw that staff were polite with people. Staff offered reassurance and support to people when they appeared anxious. Staff took time to have meaningful conversations with people and provided people with interesting things to do. A person told us, "The staff have always treated me with respect. They're very good."

We saw that people were supported to be independent. People had chosen how they wanted to spend their time. Some people kept themselves occupied whilst others were supported with activities or provided with things that interested them, for example puzzles, newspapers or tactile objects that were clearly a comfort to them.

Relatives were able to visit people without undue restrictions.

In March 2014 the home was awarded a Dignity in Care award by Leicestershire County Council.

Is the service responsive?

People told us they were well looked after. One person told us, "The staff are very helpful. They are very nice and always there to help." Records we looked at showed that people had been supported with their personal care, nursing and health needs. However, we witnessed an instance where staff had not supported a person with care for a wound in line with their care plan and we had to intervene.

People told us that they could make suggestions or raise concerns and that they were confident they would be listened to. A person who used the service told us, "I've expressed my views and opinions to staff."

The local authority social services safeguarding team investigated an allegation that one person had not received their medication. The investigation, which was concluded shortly after our inspection, found that person had not had medication they needed on seven successive days.

None of the people we spoke with could recall seeing their care plan. They could not tell us what their care plans said about how they should be supported. However, we saw from care plans we looked at that people had been involved as much as they could have been in their care plans.

Is the service well-led?

The provider had a system for monitoring the quality of service. This included reviewing all accidents and incidents that had been reported and taking steps to reduce the risk of those happening again. Routine checks of the building and premises had been carried out.

Staff told us that they had been discouraged from questioning or challenging risky or unsafe practice. Staff had raised concerns with ourselves and the local authority that they had been bullied and harassed. The provider had acted on those concerns by suspending the registered manager.

The service had procedures for reporting of accidents and injuries. We saw that reports were reviewed and analysed and that action had been taken to reduce the risk of the same type of accident occurring again.

The provider had used a satisfaction survey to obtain people's views. The most recent survey showed that people were happy about the quality of care and support they had received and their experience of living at the home.

During our inspection we met a number of people using the service and spoke with four of these in detail. All told us that they were satisfied with the care and support they received at Kirby Grange. One told us, “It is excellent here. I would not stay if it wasn’t.” Another said, “The staff here are very good to me. They look after me well and make sure I am OK.”

People had been asked to sign to confirm their agreement with aspects of the care delivered to them. Staff took people’s individual communication needs into account when asking for their consent in relation to their day to day care and support.

People’s needs had been assessed and plans put in place to explain the arrangements for their care and support. Risk assessments were used to help identify any potential risks to the welfare and safety of people using the service.

The building was kept secure and was maintained and decorated to a satisfactory standard.

There were effective recruitment and selection processes in place and appropriate checks were completed prior to new staff starting work.

There was a complaints system available and people using the service had opportunities to make comments or raise concerns, should they wish to.

This was a follow up inspection to check that the provider had taken action in response to concerns raised during inspection visits on 27 June 2011 and 10 July 2012.

We found that action had been taken and improvements made. There had been significant improvement to the information collected and recorded on people’s care plans. There were also greater opportunities for people to participate in social and recreational activities following the appointment of an activities organiser.

People told us what it was like to live at this home and described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed 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 a CQC inspector who was accompanied by an Expert by Experience (people who have experience of using services and who can provide that perspective).

To help us understand people’s experiences we used the Short Observational Framework for Inspection (SOFI). This is a specific way of observing care to help us understand the experiences of people who could not talk to us.

During our inspection visit to Kirby Grange we met a number of people who used the service and some of their visiting relatives. We spoke in detail with five of the people who used the service, and one visiting relative, to ask them for their views on the service they received.

Overall, the people we spoke with told us they were satisfied with the care and support they received. One told us, “Staff treat me with respect and affection.” Another said, “Staff go out of their way to please us.”

People made positive comments about the meals that were provided, including “food is spot on” and “most of the time the food is good.”

People who used the service at Kirby Grange told us they were satisfied with the care they received. They felt safe and well looked after, and staff responded promptly to their requests for assistance. People were happy with the quality of food provided and meal routines took into account their individual preferences and needs.