This inspection took place on 11 and 23 January 2019 and was unannounced.

Grace House is a care home for up to ten people that specialises in the care and support of older people and people living with dementia. There were nine people using the service at the start of our inspection visits.

The accommodation is purpose-adapted with passenger lift access to both residential floors. People living in this care home receive accommodation along with 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 service had two registered managers 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.

At our last inspection in September 2017 we rated the service good. At this inspection we found the evidence supported a rating of requires improvement. This was primarily because a number of recruitment checks of newer staff had not been completed, to make sure they were of good character and safe to be working with people. We also found the service’s own fire safety checks had seldom been recorded as occurring in recent months, albeit this was restarting as a result of the inspection. These factors put people at risk of receiving an unsafe service. We also found the provider’s governance processes had not identified and addressed these concerns.

Nonetheless, there was much evidence available which demonstrated that the service was providing people with individualised care that was meeting their needs. For example, people and their representatives praised the service. A typical comment was, “It’s excellent here, it’s more like lodging with somebody than a care home.”

We found that the service was caring and respectful. The atmosphere was homely, welcoming and calm. Staff provided support in a kind, professional and attentive way. They had time for people, and responded well to them.

People's independence was promoted, but within a safe context. They 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.

People's health needs were monitored and addressed by the service and through liaison with community healthcare professionals. The service provided nutritious home-cooked meals. Medicines were properly and safely managed. The service protected people by the prevention and control of infection.

There were enough staff working at the service, some of whom had been working there many years and so knew people using the service very well. Staff had the skills, knowledge and experience to deliver effective care and support. They were supported in their roles, for example, through developmental supervision, training, and direct guidance.

The service promoted a positive and inclusive culture that achieved good outcomes for people. People’s concerns were responded to, and used to improve the quality of care.

Some systems at the service enabled sustainability and supported continuous learning and improvement. For example, there was ongoing work to improve care records, expand staff knowledge, and develop health and safety standards.

This is the second time the service has been rated Requires Improvement. We found one breach of regulations at this inspection. You can see what action we told the provider to take at the back of the full version of the report.

This focused inspection took place on 18 July 2017 and was unannounced.

Our previous inspection of this service was in November 2016. Breaches of legal requirements were found, in respect of safe care and treatment and good governance. We rated the service as Requires Improvement.

After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breach. We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection by selecting the 'all reports' link for this service on our website at www.cqc.org.uk.

Grace House is a care home for up to ten people that specialises in the care and support of older people and people living with dementia. There were nine people using the service when we inspected.

The service had a registered manager, which 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 this inspection, we found that the provider had followed their plan and legal requirements had been met. There were better overall risk management processes for falls prevention and management. There had been few falls at the service, and responses to those that occurred were appropriate in terms of treatment and minimising future risks.

People's looked-after medicines were better managed and so people were safely supported to take them as prescribed. Staff had received further training on a number of safety-related topics including medicines and falls management.

Auditing reports were accurate and identified where service-delivery risks may be occurring, so demonstrating more effective governance at the service.

People we spoke with and their visitors praised the service highly and told us they would recommend it to others.

This was an unannounced inspection that took place on 31 October and 9 and 22 November 2016. At our last inspection in March 2016, we found ten breaches of regulations. These included medicines management, risk management, care planning, embedding the principles of the Mental Capacity Act 2005 into practice, safe recruitment, and effective governance. Our overall rating of the service from that inspection was ‘Inadequate.’

We undertook this comprehensive inspection to check on the progress made by the provider, and to consider whether the service could be removed from Special Measures, our framework to ensure a timely and coordinated response where we judge the standard of care to be inadequate.

Following the last inspection, we also took enforcement action. We imposed a condition on the provider's registration requiring them to send us monthly reports about auditing risk assessments of people using the service, medicines administration, and staff recruitment checks. This included any actions being taken to address any risks identified in those audits. The provider submitted these monthly. The reports indicated that progress was being made at addressing our previous concerns.

Grace House is a care home for up to ten people that specialises in the care and support of older people and people living with dementia. There was one vacancy when we inspected.

The service had a registered manager. 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 and associated Regulations about how the service is run.

People using the service and their relatives provided good feedback about the service’s care and attentiveness. We found that the service was caring and respectful, and made efforts to improve the quality of people’s lives. The environment was homely and welcoming, and the service helped people maintain community links.

Staff provided support in a kind, professional and attentive way. Staff worked to find the best outcomes for people they cared for, whilst valuing and prompting people’s independence. There was good feedback about how well the service responded to people’s requests and provided individualised care.

People’s care plans had been reviewed and updated, and addressed their support needs. There were also better activities provided. People’s health needs were addressed, including through the support of community healthcare professionals, and through nutritious home-cooked meals. The service was now working in line with the principles of the Mental Capacity Act 2005.

A management consultant had been recently hired to assist with implementing service improvements. We saw their input, including the guidance of staff on appropriate care practices, as progress towards addressing our concerns.

However, we found insufficient improvement in the management of the service. Whilst criminal record checks (DBS) were now in place for established staff, recruitment checks of new staff were still not completed before the staff member started providing care to people. Audits of those checks were additionally inaccurate.

There were better overall risk management processes but they were not yet sufficient for falls prevention and management.

People’s medicines were not always properly managed so as to maintain an audit trail that demonstrated that people were consistently offered their medicines as prescribed.

Auditing reports contained some inaccuracies that did not assure us of consistently effective governance at the service.

There were overall two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The condition on the provider’s registration that we imposed therefore remains in place.

This service has been in Special Measures. Services that are in Special Measures a

This was an unannounced inspection that took place on 18 and 22 March 2016. Our previous inspection of September 2013 found that the service had addressed concerns with staff supervision and training, and effective governance, which we had previously identified.

Grace House is a care home for up to ten people that specialises in the care and support of older people and people living with dementia. There were two vacancies when we inspected.

The service had a registered manager. 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 and associated Regulations about how the service is run.

People using the service and visitors provided good feedback about the service. They were satisfied with the staffing levels and said the staff team were caring, attentive and provided the support they needed in a friendly and kind way. They were also happy with how the service was managed.

We found that the service was caring. Staff provided professional and attentive support to people in a caring manner. The care was centred on people’s individual needs and preferences. The service supported people to eat nutritious diets and drink enough. People’s health needs were addressed, including through the support of community healthcare professionals.

The service provided sufficient numbers of staff, and standards of cleanliness were maintained. Staff benefitted from regular training, particularly the new National Care Certificate which is a set of minimum standards that staff should uphold in their daily working life and which new staff must be trained on.

However, we found some significant concerns about how the service was operated that particularly undermined people’s ongoing safety. Criminal record checks and appropriate references were not in place for a number of newer staff, meaning the provider had not taken necessary steps to ensure that these staff were safe to work with people.

Records could not demonstrate that people were consistently offered their medicines as prescribed. There were also shortfalls with the security of medicines and with ensuring emergency first-aid kits had equipment that was not out-of-date.

Risk management processes were not comprehensive. They did not ensure that all reasonable actions were taken to minimise risks to people using the service. Parts of the premises were avoidably cold during one of our visits. Following an accident to one person, we could not be assured that sufficient action had been taken to minimise the risk of reoccurrence.

Whilst efforts were made to address people’s needs in practice, people’s care plans did not consistently address all their support needs and sometimes contained contradictory information. This had potential to undermine appropriate care practices.

Records of the care provided to people, and of the management of the service, were not consistently up-to-date and complete. This undermined appropriate care practices and meant information could not always be easily accessed.

The service had not embedded the principles of the Mental Capacity Act 2005 into its practice. Whilst some people were being deprived of their liberty for their protection, applications to undertake this lawfully had not been made.

We also found concerns with how well-led the service was. There were few recorded governance systems in place, and so we identified shortfalls that the management team and the provider had not recognised or addressed.

The provider had not kept us notified when significant events occurred at the service, contrary to legislation. This prevented us from monitoring the service effectively.

There were overall eight breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and two breaches of the Care Quality Commis

We spoke with five people who use the service and two relatives. Most people praised the service and the care provided. Comments included, “there is an outstanding level of care” and “I’ve got a good quality of life here.” Staff and the manager knew people as individuals. We found that people experienced care that met their needs and protected their rights, and that most people’s views and experiences were taken into account in the way the service was provided and delivered in relation to their care.

We found that people were protected from the risk of abuse because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. People were also protected from the risks of unsafe or inappropriate care because appropriate records about their care were maintained and securely stored.

However, there were occasions when some staff did not interact with people appropriately, for example, with manual handling and with communicating effectively. We found that the provider did not have suitable training, supervision and appraisal arrangements in place to ensure that care was delivered to people safely and to an appropriate standard.

We also found ineffective management audit tools to assess and monitor care quality, and identify, assess and manage risks relating to the health, welfare and safety of people. This failed to protect people against the risks of inappropriate or unsafe care.

There were nine people in residence and we spoke with four, along with relatives and friends who gave us positive feedback about the services provided. They commented on the suitability of food, safety and appropriateness of care, support with taking medicines, and staff competency, and in all accounts expressed satisfaction.

Commenting about food that is served at the home, one person told us, “l have never been served anything l don’t like”, and another told us, “the food is excellent.” Their views were supported by relatives and friends who shared lunch with them that afternoon. A relative told us, “l have been here four times and the food is fine.”

People were content with the treatment and support they experienced, which they attributed to staff’s awareness of their needs and staff competency. One person told us, “staff know what they are doing”.

The same reaction was expressed when we explored views about whether people were having their medicines at the times they needed them. For example, one person said, “l am given my medicines on time”.

People told us what it was like to live in 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 Care Quality Commission (CQC) Inspector joined by an Expert by Experience; people who have experience of using services and who can provide that perspective. We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk to us.

People told us that they were given choices about the food and drink provided at the home When asked whether they liked their breakfast, one person told us “yes, if I didn’t I would say.” People knew who to complain to if they had any problems. People told us that they felt safe at the home.

People who use the service were satisfied with the care provided and they indicated that their care needs had been attended to. They spoke highly of staff and stated that they had been treated with respect and dignity. Their views can be summarised by the following comments :

"I am well treated here. My health has improved.”

We observed that people who use the service appeared relaxed and comfortable. There was frequent interaction between staff and people who use the service. Staff were responsive and gentle when responding to people who use the service. People who use the service said they were happy with the accommodation and facilities. We noted that the home was clean and tidy and furnished to a high standard.

We were able to speak to a relative. The feedback received was positive and indicated that people who use the service were well cared for and they had been consulted regarding the care provided. The relative made the following comment:

“Staff are excellent and have been very helpful to my relative. They have done all they can for my relative. I am very grateful.”

We carried out this inspection to check whether the provider had addressed the compliance actions arising from our last inspection of 11 July 2013. At that time, the training and supervision of staff was not providing appropriate support to them in relation to their responsibilities of delivering care to people safely and to an appropriate standard. Additionally, management audit systems used were ineffective in terms of assessing and monitoring care quality in relation to the health, safety and welfare of people.

At this inspection, we found that matters had been addressed. Staff were now receiving training to help update their skills, for example, on food hygiene, safeguarding, and dementia care. We found that systems of supervising staff had been implemented. Staff were being supported to provide people with safe and appropriate care.

We found that the provider now had systems to regularly assess and monitor the quality of service that people received. We were shown how people’s comments were being used to improve the services provided. There was also evidence that the views of staff were being sought, to help make service improvements.

We spoke briefly with a couple of people who use the service as part of this inspection. They were both happy with the services provided. “I lead an interesting life, receive good food and service,” was one of the comments.