About the service: The Grange Residential Home provides accommodation and support for up to nine people who have a learning disability. On the day of our visit, there were seven people living in the service.

At our last inspection in November 2017 we were concerned that people were not supported and encouraged to be independent. At that time people did not live in an environment that valued and underpinned the best practice guidance. Following that inspection, we met with the registered manager and deputy manager and discussed their action plan for making the necessary improvements.

At this inspection we found the necessary developments had been made. The registered manager and staff were working within the principles and values that underpin Registering the Right Support and other best practice guidance. This ensured that people could live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence.

People’s experience of using this service:

There were enough, suitably recruited staff who worked well as a team to ensure people received the care and support they needed.

People received personalised care which met their needs and risks were well managed.

Medicines were managed safely and records evidenced that people had received their medicines as prescribed.

People were treated with dignity and their privacy was respected. They were supported to make choices and decisions for themselves and encouraged to express their views.

People made their own choices about where they spent their time and had the opportunity to participate in a range of recreational and social activities.

People were supported with good nutrition and could access appropriate healthcare services when needed them.

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.

The registered manager had managed and run the service for 30 years, staff were also long serving and all knew people and their support needs very well.

Rating at last inspection: The service was rated ‘Requires Improvement’ at our last inspection. The report following that inspection was published on 12 February 2018.

Why we inspected: This was a planned inspection based on the rating at the last inspection.

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

The Grange Residential Home is a residential care home that provides accommodation and personal care for up to nine people who have a learning disability. There were eight people living in the service when we inspected on 8 and 16 November 2017. The inspection was unannounced on the first day. On the second day we arranged with the registered manager the date that we would return as we wanted to speak with people who lived at the service at this was when they were at home.

At the last inspection in July 2016 the service was rated as ‘Requires Improvement’ in three of the key questions we ask and overall. At this inspection we have continued concerns in a number of the key questions. The service has been rated ‘Requires Improvement’ in three of the key questions and as a result overall again.

The Grange Residential Home 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 Grange Residential Home accommodates up to nine people in a house which was situated in a residential area of Bury St Edmunds, Suffolk.

The care service has not been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen. People did not live in an environment that valued and underpinned the best practice guidance.

There was a registered manager in post at the time of our visits. The registered manager was also the provider and the owner of the company Grange Residential Homes Ltd who runs the home. 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 provider and registered manager has been referred to as the registered manager throughout this report.

Staff did not always encourage choice and independence for people by providing opportunities for people to increase their independence. People did not always receive personalised care that was responsive to their needs. Quality assurance systems in place had not identified areas where we found concerns, and therefore these needed improving.

There were sufficient staff deployed to support people with their personal care and their preferred activities at home and in the wider community. Staff had an understanding of abuse and safeguarding procedures. They were aware of how to report abuse as well as an awareness of how to report safeguarding concerns outside of the service. Staff undertook safeguarding training providing them with knowledge to protect people from the risk of harm.

People's medicines were administered safely by staff who were trained to do so, and medicines were stored securely. Risks to people and the environment were assessed but not always and reviewed and updated in a timely manner. Staff knew people very well which helped to mitigate against any risk assessments not reviewed.

People's right to make decisions about their care was respected and those people, who lacked capacity to make their own decisions, had been appropriately supported under the principles of the Mental Capacity Act 2005.

People received a service that was caring. The registered manager and staff knew people very well and supportive. Staff treated people with dignity and respect. People were offered a range of activities both at the service and in the local community.

The inspection took place on 12 July 2016 and was unannounced.

The service is registered to provide care and support for up to nine people with learning disabilities. At the time of our inspection eight people were using the service.

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.

Staff were trained in safeguarding people from the risk of abuse and systems were in place to protect people from all forms of abuse including financial. Staff understood their responsibilities to report any safeguarding concerns they may have, although they did not know how to report concerns externally.

Risks had been assessed but actions had not always been taken to reduce these risks and some actions were not robust. Risk assessments were in place but some had not been appropriately reviewed. A new records system was being implemented and assessments were being updated as part of this project.

Staffing levels matched the assessed safe levels. Recruitment procedures, designed to ensure that staff were suitable for this type of work, were robust.

Medicines were administered safely and records related to medicines management were accurately completed. A concern was identified with regard to the management of medicines for people when they were away from the service.

Staff training was provided and regularly updated. Some relevant training had not been provided to all staff.

Staff had not received training in the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS) at the time of our inspection but this has been provided since. The MCA and DoLS ensure that, where people lack capacity to make decisions for themselves, decisions are made in their best interests according to a structured process. Where people’s liberty needs to be restricted for their own safety, this must done in accordance with legal requirements. An appropriate application had been made for one person but had not yet been authorised.

People were supported with their eating and drinking needs and staff helped people to maintain good health by supporting them with their day to day healthcare needs.

Staff were very caring and treated people with kindness making sure their dignity was maintained. Staff were positive about the job they did and enjoyed the relationships they had built with the people they were supporting and caring for. However, some decisions were made without due regard for the people who used the service.

People, and their relatives, were involved in planning and reviewing their care and were encouraged to provide feedback on the service. Care plans were in the process of being reviewed in order to reflect people’s current needs.

There was a complaints procedure but no formal complaints had been made. Informal concerns had been managed well.

Staff understood their roles and felt well supported by the management of the service, although structured supervision was not regular.

Quality assurance systems were in place and action had been taken to address any concerns. Record keeping was good and there was clear management oversight of the day to day running of the service. The manager had not submitted all the required notifications regarding health and safety matters to CQC.

We found a breach of regulations during this inspection. You can see what action we have told the provider to take at the back of this report.

We spoke with five people using the service and they all confirmed to us that they were happy, felt safe and were well cared for by staff. One person told us, "Staff help me to go out if I want to." Another person said, "I love helping in the garden." A third stated, "I love living here." We sat with people over lunch and found that the atmosphere at the service was both homely and relaxed. People chatted with one another and enjoyed interactions with staff. We spoke with two relatives and a healthcare professional who all confirmed that the service was meeting people's needs.

Risk assessments and support plans were in place for all people using the service. These clearly demonstrated the way that risks were managed and how staff could best assist in meeting people's daily care needs. People were supported to access the services of other health and social care professionals. We saw evidence that people had been supported to record their long term and short term goals and that staff were assisting people to achieve what was important to them.

Staff understood their role in relation to safeguarding the vulnerable people using the service. Appropriate checks had been made prior to staff working at the service, to ensure that they were fit ad qualified to work in a care environment.

Quality and monitoring systems were in place to ensure the health and safety of people using the service, visitors and staff. Feedback was requested and was used to improve care.

We spoke with five people using the service during our inspection on 20 August 2012. They told us that staff were polite and respectful. They confirmed that they were able to make decisions about what they wanted to do during the day, including when they wished to get up and go to bed. Everyone we spoke with told us that they felt safe and that they were happy and well. Tenant meetings were held and people confirmed they could attend if they wanted to.

One person using the service told us, “I feel safe. I like to go out to the cinema and to help in the garden. I am happy living here and staff are kind to me.”