About the service:

Darenth Grange Residential Home is a residential care home providing personal care to up to 29 people aged 65 and over. There were 18 people living at the service at the time of inspection. People had varying care needs, including, living with dementia, Parkinson’s disease and diabetes. Some people could walk around independently and other people needed the assistance of staff or staff and equipment to help them to move around.

For more details, see the full report which is on the CQC website at www.cqc.org.uk

People’s experience of using this service:

¿ Although the service met the characteristics of Good in Effective and Caring, there were three areas, Safe, Responsive and Well Led that Required Improvement.

¿ The medicines people were prescribed to take were not always recorded and managed in a safe way.

¿ Risks within the premises and environment had not always been identified to make sure management plans were in place to reduce the risks to people.

¿ Measures were not always in place to make sure the spread of infection was suitably controlled.

¿ People were not always provided with activities to meet their interests and avoid social isolation. Care plans did not always provide individual guidance and a person-centred approach to people’s care.

¿ Opportunities were missed through the provider’s monitoring and auditing systems to identify the areas of quality and safety that needed improvement, so that action could be taken in a timely manner.

¿ Complaints were not always fully responded to with outcomes clearly set out. We have made a recommendation about this.

¿ People were supported to make their own decisions on a day to day basis.

¿ Staff knew people well and many staff had worked at Darenth Grange for a number of years. Staff told us they were happy in their work and felt well supported.

¿ People were supported to maintain their independence and staff were careful to respect people’s privacy.

¿ People were encouraged and supported to express their views.

¿ The provider had enough staff to make sure people received the care and support they needed.

¿ People were happy with their meals and were able to eat in a large comfortable dining room.

Rating at last inspection:

Requires Improvement (Report published 30 March 2018). This service has been rated Requires Improvement at the last two inspections and had previously been rated Inadequate.

Why we inspected:

This was a planned inspection based on the previous rating.

Enforcement:

Please see the ‘action we have told the provider to take’ section towards the end of this report.

Follow up:

We will continue to monitor this service and plan to inspect in line with our inspection schedule for those services rated Requires Improvement.

The inspection took place on 5 and 6 February 2018. The inspection was unannounced on the first day. We told the provider and manager when we would return to complete the inspection.

Darenth Grange is a ‘care home’. People in care homes receive accommodation and nursing and 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. Darenth Grange provides accommodation and support for up to 29 older people. There were 18 people using the service at the time of our inspection. Some people were unable to communicate verbally with us. People had varying needs including diabetes and Parkinson's disease and some people were living with dementia. Some people required the use of a hoist to help them to move from their bed to a chair and vice versa and others required one member of staff to walk with them. Others were able to walk around unaided. Three people had frail health which meant they were cared for in bed. The registered provider had 25 single bedrooms and two bedrooms that could either be used as a single bedroom or shared by a couple. No people were sharing a bedroom at the time of our inspection.

There was a new manager in post, however, they were not yet registered with the Care Quality Commission (CQC), although they had applied to register and their application was in progress. 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.

At our last inspection on 5 and 10 July 2017 we found breaches of Regulations 9, 10, 11, 12, 13, 15, 17 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Five breaches had continued since the previous inspection relating to the management of risk to individuals’ safety including the safe management of medicine administration and control of infection, consent, person centred care, suitable and safe premises and equipment and governance systems. Three further breaches were identified relating to safeguarding vulnerable adults, dignity and respect and staffing. We placed the service in special measures for the second time and initiated action against the provider. This inspection took place to check that the provider had made improvements in the areas that required improvement.

At this inspection, we found the provider had made a number of improvements within the service, although some improvements were still in progress and further work was continuing.

People and their relatives told us they received care that was safe, effective, caring, responsive and well led.

The provider had taken the decision not to admit any new people into the home since the last inspection. This gave them the opportunity to spend time improving the quality and safety of the service.

At this inspection, we found that sufficient improvement had not been made to ensure people’s basic rights were upheld within the principles of the Mental Capacity Act 2005. Some people had not had their mental capacity assessed when required and decisions around consent were not always appropriate.

Although the provider had carried out identified essential work to the premises, further work was required to ensure the premises were of a suitable standard to provide a safe and good quality environment for people to live in.

Improvements had been made to people’s individual risk assessments, however further work needed to be carried out to ensure the level of information recorded and the measures to keep people safe were in place and fully accessible by staff.

Risks associated with the premises and environment had been identified and the measures taken to prevent harm had been recorded. However, the detail

We inspected Darenth Grange on the 5 and 10 July 2017. The first day of the inspection was unannounced. Darenth Grange is a care home providing accommodation, personal care and support for up to 29 older people and older people living with dementia. There were 28 people using the service at the time of our inspection. Not all were able to communicate verbally with us. The registered provider had 25 single bedrooms and two bedrooms that could either be used as a single bedroom or shared by a couple. One bedroom was being used as a shared bedroom at the time of the inspection.

There was a manager in post who was registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the 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 our last inspection, in November 2016, we found seven breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches related to the management of risk to individuals’ safety, person centred care, consent, staff support, governance systems, displaying their rating notifications of significant events. We issued a warning notice to the registered provider for the breach of regulation relating to governance. The registered provider sent us an action plan telling us they would become compliant with the regulations by 31 March 2017. This inspection took place to check that the registered provider had made improvements in these areas. We found that some improvements had been made, but the registered provider continued to breach four regulations and was also in breach of a further four regulations.

People were not always safeguarded from abuse because the registered manager had not recognised and responded appropriately to allegations of abuse. People told us they felt safe using the service however we found that the service was not always managed in a way that ensured their safety. Risks to people’s safety and welfare had not always been managed appropriately to ensure they were minimised. Where people had been assessed as being at risk of dehydration there was not an effective plan in place to monitor their fluid intake and take action when they were not drinking enough. People’s medicines were not always managed safely. The registered manager did not make checks to ensure that staff were competent in administering medicines safely. The registered provider had not ensured there were effective systems to reduce the risk of infection spreading in the service.

Staff were encouraged to gain qualifications relevant to their roles and they received essential training to enable to carry out their roles. Staff received regular supervision and an annual appraisal in line with the registered provider’s policy. However, the registered manager did not always provide staff with appropriate feedback about their performance and did not follow the registered provider’s disciplinary procedure to respond to concerns about staff performance. The registered provider had systems in place to check the suitability of staff before they began working in the service. There were sufficient numbers of staff on duty to meet people’s needs in a safe way.

The registered manager and staff had not always met the requirements of the Mental Capacity Act 2005 (MCA). People are not supported to have maximum choice and control of their lives and staff do not support them in the least restrictive way possible; the policies and systems in the service do not support this practice. There was a lack of understanding by the registered manager about the principles of the MCA. However, on a day to day basis staff sought people’s consent before they provided care.

The registered provider had not ensured that the premises were properly maintained, clean, saf

We inspected Darenth Grange on the 4 November 2016 and the inspection was unannounced. Darenth Grange is a care home providing accommodation, personal care and support for up to 29 older people and older people living with dementia. There were 28 people using the service at the time of our inspection. Not all were able to communicate verbally with us. The registered provider had 25 single bedrooms and two bedrooms that could either be used as a single bedroom or shared by a couple. One bedroom was being used as a shared bedroom at the time of the inspection.

There was a manager in post who was registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the 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 our last inspection, in November 2015, we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches related to the management of risk to individuals’ safety, medicines, maintenance of the premises, staff support, dignity and respect, personalised care and governance systems. The registered provider sent us an action plan detailing when they would become compliant with the regulations. This inspection took place to check that the registered provider had made improvements in these areas. We found that not all the required improvements had been made and the registered provider continued to breach regulations.

People told us they felt safe using the service however we found that the service was not always managed in a way that ensured their safety. Risks to people’s safety and welfare had not always been managed appropriately to ensure they were minimised. There was not an effective system in place for reducing the risk of harm if there was a fire in the building. Staff were not provided with the information they needed to help people move safely around the building and to evacuate the building in an emergency. Where people had been assessed as being at risk of dehydration there was not an effective plan in place to monitor their fluid intake and ensure they had enough to drink.

People’s medicines were not managed safely. There were errors in the completion of records about the medicines stored in the service and the medicines people took. Staff did not have clear written guidance to inform them of the situations where they should give people medicines that were prescribed to be taken ‘as required’. This meant that people may not receive their medicines when they need them and in a consistent way.

People told us that staff had the knowledge and skills to meet their needs. Staff were encouraged to gain qualifications relevant to their roles. Staff received essential training to enable to carry out their roles effectively, but this had not always been updated when the certificate had expired. Staff had not received regular supervision and annual appraisal in line with the registered provider’s policy.

The CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The registered provider and registered manager had not met the requirements of the Mental Capacity Act 2005. They had not ensured that new applications were made for DoLS authorisations once an authorisation had expired.

People’s care was not planned in a personalised way. People’s care plans were limited in the information they provided and did not reflect their individual preferences. Staff were not provided with information about people’s dementia to ensure they could meet their specific needs in a personalised way. Information about people’s past occupations and hobbies had not been used to write a care plan that met their social and occupational needs. The lack of recorded information ab

The inspection was carried out on 18 November 2015 by one inspector. It was an unannounced inspection. The service provides personal care and accommodation for a maximum of 29 older people who live with dementia. The service provides both permanent and respite places. There were 27 people living at the service at the time of our inspection.

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.

The registered manager was supported by a deputy manager and a team of senior carers to ensure the daily management of the service.

We last inspected the service in July 2013 and found the service was not compliant with the regulations. There were shortfalls in seeking consent, providing personalised care and supporting staff. The provider wrote to us to tell us what action they had taken to improve the service. At this inspection we found that some improvements had been made, but shortfalls in the supervision of staff and provision of personalised care remained. There were some breaches of regulations.

The registered provider had not ensured that risks to individuals, and within the premises, were appropriately assessed and minimised, for example the risk of refusing care and the management of emergencies. The premises had not been well maintained and there was a lack of business planning in place to ensure improvements were made.

People’s medicines were not always managed in a safe way. Records were not always completed accurately and there was a lack of guidance for staff to follow about when to administer medicines prescribed to be taken ‘as required’.

Staff were not appropriately supervised and supported to ensure they carried out their roles effectively and safely. Not all staff had an annual appraisal of their performance in line with the registered provider’s policy.

Most of the staff were caring and kind in their approach and demonstrated compassion and patience when supporting people. However, this did not happen consistently. Some interactions between staff and people using the service did not demonstrate respect for the individuals or provide them with compassionate and dignified care. Generally throughout the day staff promoted a person centred culture in the service, but we noted that the culture at mealtimes was task focused more than person centred.

People’s needs were not assessed fully and their care was not planned and regularly reviewed in a way that reflected and met their individual needs, preferences, and social history.

The registered provider had not ensured accurate and complete records were maintained in relation to people’s needs, the care provided and the running of the service. This meant that staff and the registered manager could not be assured that people had been provided with the care they needed.

The registered provider did not have effective systems in operation for checking and improving the quality and safety of the service. There were a number of shortfalls found in this inspection that had not been identified through the registered provider’s quality monitoring systems.

Staff were trained in recognising the signs of abuse and knew how to refer to the local authority if they had any concerns. Systems were in place to protect people from abuse. Staff showed they understood the need to meet the emotional needs of people living with dementia as well as their physical needs.

Equipment used for the provision of care was appropriately maintained. Accidents and incidents were monitored and action taken to reduce the risk of them happening again.

There were enough staff employed, with the right skills and experience, to meet people’s needs. The registered provider en

We found there was a risk that people’s views were not taken into account in relation to the way the service was delivered.

We found the provider had taken steps to address the concerns we raised as a result of our previous inspection. This was in relation to the action they took following an incident to ensure the safety and welfare of the people who used the service.

Staff we spoke with had a good understanding of people's dietary needs, their likes and dislikes. One person who used the service said "I get three good meals a day and I get a choice" and another person told us the meals were “as good as I would cook myself”.

We found the provider had not afforded staff the opportunity to talk through any issues about their role with their line manager in a structured way through regular supervision and the professional development of staff had not been supported through a regular system of appraisal.

As part of our inspection we spoke with six people who used the service about the care and support they received. We also spoke with the Deputy Manager and three support staff. During the inspection we noted that staff interactions with people were positive and people seemed at ease and relaxed in the home.

People told us they liked living at the home and were happy. One person said "It's nice" and "Staff try their best". We saw that people had been involved in their plan of care, but found concerns that people's daily routines had not always been included.

We found that CCTV was used and recorded in the home. The service were not able to evidence that appropriate information had been provided to people who used the service to make them aware that certain areas were monitored.

We saw that the service had completed appropriate risk assessments for people who lived in the home to help staff maintain people's safety and wellbeing, but found concerns that these were not reviewed following incidents to minimise the risk of future incidents.

People told us that they felt "Safe" and "Secure" in the home. They told us that if they had any concerns then they would speak with the manager and were confident the appropriate action would be taken.

Staff told us they "Loved" working at the home and felt "Supported" by their manager. We found that appropriate checks were in place to confirm the suitability of staff to work with vulnerable people.

People said they liked living at Darenth Grange. They said they had visited the home before admission and been involved in discussions about the help they needed and their preferred day to day routines. People said there were different activities to do and that they could join in with activities if they wanted to. They said they were happy with the support they received, that the staff looked after them well. People said they liked the food, there was a choice of menu and that they chose where to eat. They said that the home was always kept clean and smelled fresh. People said they knew who to speak to should they have any concerns, but said they had no complaints.