This inspection took place on 4th, 13th and 15th June 2018 and was unannounced.

When we completed our previous inspection on 5th June 2017 we found concerns relating to record keeping processes which were ineffective in monitoring and improving the quality and safety of the service, assessing and mitigating risks and maintaining contemporaneous records of each person using the service. At this time these topic areas were included under the key questions of Responsive and Well-Led. We reviewed and refined our assessment framework and published the new assessment framework in October 2017. Under the new framework these topic areas are included under the key question of Effective and Well-Led. Therefore, for this inspection, we have inspected these key questions and also the previous key question of Responsive to make sure all areas are inspected to validate the ratings.

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

Beverley Grange provides accommodation and support to a maximum of 75 people some of whom may be younger or older adults that may have physical disabilities and/or living with dementia. At the time of our inspection there were 59 people using the service. The home is purpose built and split into two areas, the first floor is for those people requiring nursing care and the ground floor for people that are more mobile and independent. There are seven bungalows within the grounds of the home three of which were occupied at the time of this inspection. People could live as independently as they could with support available if needed. A large garden with a greenhouse and raised beds of flowers surrounded the home and parking is available on site. The home is located on the outskirts of Beverley in East Yorkshire.

There was a registered manager in post at the time of this 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.

Staff had exceptional skills and expertise to empower people and their families to be involved in the care planning process. Management supported staff by offering specialist training which supported them to achieve responsive and effective care outcomes.

Records showed staff were innovative and proactive in their approach. Staff worked above and beyond to support people, they arranged multi agency support frameworks, offered support for those transitioning back into the community and worked tirelessly to ensure nursing care was continuously improved to demonstrate high standards of achievement in areas such as pressure care.

Staff were highly skilled at enabling people to explore different innovative communication methods find those that best suited individuals and their capabilities. Relatives told us that staff were patient, friendly and very kind when facilitating people’s freedom to express themselves. This supported an inclusive environment with equal opportunities for all people living at the service.

Relatives feedback praised staff for their kindness and professional manner towards those people requiring palliative care. Staff spoke passionately about ensuring people were comfortable and meticulously cared for during end of life care. Relatives had thanked staff for their exceptional support, care and attention during difficult times.

Staff took time speaking with people about their life histories and captured this information to support people to achieve their future aspirations. People were encouraged to get involved with activities and event planning that incorporated parts of th

This inspection took place on 5 June 2017 and was unannounced.

Beverley Grange Nursing Home provides accommodation and care for a maximum of 75 people over the age of 18. The service provides support for people who may be living with dementia or who may have a physical disability. At the time of our inspection there were 56 people using the service.

The provider is required to have a registered manager as a condition of their registration for this service. A registered manager is a person who has registered with the Care Quality Commission (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. At the time of our inspection, the service did have a registered manager and we have referred to them as 'the manager' throughout this report.

Quality assurance and record keeping within the service needed to improve. There was a lack of effective auditing within the service. We found that care plans, risk assessments and food/fluid charts were not always accurate or up to date. This meant that staff did not have access to complete and contemporaneous records in respect of each person using the service, which potentially put people at risk of harm. This is a breach of Regulation 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

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

People told us they felt safe and were well cared for. The provider followed robust recruitment checks, to employ suitable people. There were sufficient staff employed to assist people in a timely way. Medicine management practices were being reviewed by the manager and action was taken to ensure medicines were given safely and as prescribed by people’s GPs.

Staff had completed relevant training. We found that the care staff received regular supervision and yearly appraisals, to fulfil their roles effectively. However the frequency of supervision for new starters and the trained nurses needed to be more consistent.

People were able to talk to health care professionals about their care and treatment. People could see a GP when they needed to and they received care and treatment from external health care professionals when necessary, such as the district nursing team and speech and language therapists.

People had access to adequate food and drinks and we found that people were assessed for nutritional risk and were seen by the Speech and Language Therapy (SALT) team or a dietician when appropriate. People who spoke with us were satisfied with the quality of the meals.

People were treated with respect and dignity by the staff. People and relatives said staff were caring and they were happy with the care they received. They also confirmed they had been included in planning and agreeing the care provided. People had access to community facilities and most participated in the activities provided in the service.

People and relatives knew how to make a complaint and those who spoke with us were happy with the way any issues they had raised had been dealt with.

People told us that the service was well managed and organised. People and staff were asked for their views and their suggestions were used to continuously improve the service.

The inspection took place on 10 March 2015 and was unannounced. The last visit of the service was on 5 August 2014 when the service was found to be in breach of legal requirements. These were in relation to staffing, safeguarding of vulnerable people and medicine management. We had received information from the provider after this visit to declare they had taken actions and now met the legal requirements. Consequently this visit included a review of the action taken and found the provider had met all of the legal requirements.

Beverley Grange is a purpose built home situated on a housing development in a residential area on the outskirts of Beverley. It is set in its own grounds with plenty of space for people to sit and enjoy the fresh air. The service was opened in 1999 and provides long term and respite stays, looking after people who need residential care or nursing care. Respite stays are usually short periods at the home often used to allow people time to recover from illnesses or injuries.

At the time of the visit 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.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which apply to care homes. DoLS are part of the Mental Capacity Act (MCA) 2005 legislation which is in place for people who are unable to make decisions for them. The legislation is designed to make sure any decisions are made in the person’s best interest. We found people were supported with this.

People living in the home told us they felt safe. People had risk assessments in place which identified any risk in their lives and helped prevent harm occurring. People were supported by staff who had been trained in and knew what actions to take should an allegation of harm be raised.

People were supported by staff who had been recruited through a system which required only minor improvements. We received some comments whereby people felt there could be more staff in the home although people told us their needs were met.

People received support to help make sure their rights were respected. Staff had received training in the Mental Capacity Act (MCA) although not all staff were clear on their understanding of this.

People felt staff were competent in their role and staff had received training.

People’s nutritional needs were identified and supported, although support with the eating of meals required improvement. People’s health and medication needs were identified and met. When necessary people accessed support and advice from health care professionals.

People were supported by staff who were caring and polite. People living in the home told us staff supported them with their independence and their privacy and dignity was respected.

Not everyone living in the home felt the manager responded well to requests. However, people did feel there was a good atmosphere in the home. Staff felt they received good support from managers.

Audits were undertaken of the systems within the home to help make sure people’s needs were safely met. However, not everyone felt consulted.

We carried out this unannounced inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008 and to pilot a new inspection process being introduced by CQC which looks at the overall quality of the service.

Beverley Grange is a purpose built home situated on a housing development in a residential area on the outskirts of Beverley. It is set in its own grounds with plenty of space for people to sit and enjoy the fresh air. The service was opened in 1999 and provides long term and respite stays, looking after people who need residential care or nursing care. Respite stays are usually short periods at the home often used to allow people time to recover from illnesses or injuries.

At the time of the visit there were 67 people living in the home.

The last inspection of this service was in January 2014. At the time the service was meeting all of the assessed areas.

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 and has the legal responsibility for meeting the requirements of the law; as does the provider.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which apply to care homes. DoLS are part of the Mental Capacity Act (MCA) 2005 legislation which is in place for people who are unable to make decisions for them. The legislation is designed to make sure any decisions are made in the person’s best interest. The registered manager told us that no-one in the home had required any support with DoLS as everyone had been assessed as being able to make decisions without this support. However, we found one person had a restriction with no evidence if this was agreed.

We found there were not enough staff to support people. People told us they did not always have their personal care needs met.

Information regarding an allegation of harm had not been handled correctly by the home; this meant people were not fully protected.

Medicines were not handled correctly in the home; records were not kept up to date and monitoring checks were inadequate.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.

Staff received training to help equip them with the necessary skills to meet people’s needs. We found assessment systems in place which recorded people’s individual needs. When we spoke with staff they were aware of these needs.

People told us staff were caring and polite and overall we observed a positive culture in the home.

There were systems in place to support people with their dietary needs, for example support relating to special diets for people with diabetes. However, support with the eating of meals required improvement and not everyone had easy access to drinks.

Activities were available to people but only in one area of the home. People who did not access this area were not provided with activities and no individual one to one activities took place.

People told us they were able to complain but how this was handled by the home varied. Additionally there were systems in the home to audit and monitor service provision. However, the records we reviewed showed that the system currently in use was mainly a tick list; we found that these lists were not completed correctly and provided no evidence of how this was used to improve the service to people who lived there.

Although meetings took place there was little evidence that consultation comments were used by management to improve service provision.

We undertook this visit to review the areas of non-compliance found at the previous inspection. This was in relation to records and record keeping in the home.

We did not speak directly with people who lived in the home as we were following up on the previous inspection when people’s views had been incorporated into the judgments at that time. No comments had been received in relation to documents or paperwork.

We found that the provider had taken action and previous issues in relation to care files had been addressed. Records were more person centred, care plans included all areas of need and monitoring forms were on the whole up to date. With only minor work now required to ensure that all details were recorded.

Staff files were more detailed and information recorded in the staffing matrix cross referenced with that held in individual files.

We saw some documents in relation to the management of the home and these were up to date.

Records were stored securely with only minor improvements required to help ensure that data was fully protected.

We undertook this inspection to follow up on previous areas of concern in relation to records in the home regarding people's care, staff training and supervision, quality assurance in the home and overall record keeping.

People who lived in the home told us “I am very satisfied” and “ I am glad I came here” when asked about life in the home. They confirmed staff were polite and we observed appropriate support being offered to people. One person confirmed they had been asked to complete a questionnaire about life in the home.

We found that the provider, manager and staff had undertaken a large amount of work in response to our concerns. However additional work was still required.

A new system of care planning had been implemented to help ensure that all of a person’s needs were recorded and supported.

New staff training records both for individual staff and an overall matrix had been updated and supervision sessions had taken place.

Maintenance records were now in place; as were risk assessments.

However improvements continued to be required as care plans did not all contain all of the relevant information and staff training record details did not match the matrix.

People told us that they felt their needs were met in the home and that they felt safe. However people were unsure who to speak with if they wished to raise a concern and they felt they would benefit from an increase in activities.

There was little evidence that people had consented to their care plans or that people were involved in the development of their packages of care. There was some information in relation to people’s choices, although we observed two instances when peoples choices were restricted. One person told us, “ I felt like I was being told off.”

Staff were aware of maintaining people’s privacy and we observed this in practice.

We found that there were discrepancies in the recording of people’s information which could have a negative impact on the care provided in the home.

We found that safeguarding issues had been reported appropriately although there was a need for an improved policy and improvements in staff training in this.

Staffing levels appeared adequate although staff training required some improvements.

Systems were in place to audit the home and to find out people’s opinions of their care. However there were some omissions in records for maintenance.

People told us that they staff were "Very good." They said that they had choices and that this included their meals.

People said that there were activities in the home that they could participate in if they wished to.

People said that there were enough staff and that they felt safe living inthe home.

We spoke to four people who use the service and they told us they were happy living at the home and with the care they received. One person told us that moving into the home was the best decision she had ever made.