Granada House 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.

Granada House accommodates up to 13 people in one adapted building. At the time of our inspection there were 11 people living at the service.

At our last inspection in April 2018 we found the service was good. At this inspection we found the service remained good.

People told us they felt safe and well-cared for at the service. Everybody was very complimentary about the deputy manager and the staff team. There were warm and affectionate relationships between staff and people who used the service.

The service provided a homely and comfortable environment where people were encouraged to bring their own furniture and pictures to personalise their rooms. People were consulted about meals and their preferences catered for.

We found the environment was suitably maintained and measures were in place to ensure people lived in safe surroundings.

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.

People’s privacy, dignity and independence were supported. Staff liaised with health professionals to help people get the care they needed and to remain healthy.

Some people had complex health needs and staff had developed clear person-centred plans which detailed the best way to provide care.

The service was well-managed by the deputy manager. Staff and people living at the service were positive about the service. Staff morale was good and there was low turnover of staff.

There was a registered manager in post, however they were based at another of the provider’s services and delegated management of Granada House to the deputy manager. The deputy manager operated an effective governance system and had a comprehensive overview of how the service was operating.

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This comprehensive inspection was carried out on 20 March 2018 and was unannounced.

Granada House 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 service is registered to provide care and support for up to 13 people, some of whom are living with dementia. Nursing care is not provided. At this inspection there were 12 people living at the home.

At the last inspection in November 2016, we rated the service as 'Requires Improvement'. You can read the report from our last comprehensive inspection by selecting the 'all reports' link for Granada House on our website at www.cqc.org.uk.

At this inspection, we found the provider had made improvements and was no longer in breach of the Regulations.

Improvements had been made to the environment to make it safe. Risks to people had been assessed and plans put in place to keep risks to a minimum.

There were systems in place to look at the quality of the service provided and action was taken where shortfalls were identified.

People told us they felt safe at the service.

Staff were confident about how to protect people from harm and what they would do if they had any safeguarding concerns.

The systems in place to make sure that people were supported to take medicines safely had been improved and were effective.

There were a sufficient number of staff on duty to make sure people's needs were met.

Recruitment procedures made sure that staff had the required skills and were of suitable character and background.

Staff were supported by a comprehensive training programme and supervisions to help them carry out their roles effectively.

The registered manager and staff were aware of the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). DoLS are put in place to protect people where their freedom of movement is restricted and they lack capacity to make certain decisions.

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.

People were provided with sufficient amounts of food and drink taking into account people's likes and dislikes and special diets.

People told us and staff demonstrated a kind and caring approach. People had their privacy and dignity respected.

Care plans showed that individual preferences were taken into account.

Care plans were up to date and gave clear directions to staff about the support people required to have their needs met. People's needs were regularly reviewed and appropriate changes were made to the support people received.

People were supported to maintain their health and had access to health services if needed.

People were encouraged to follow their interests and take part in a range of activities.

People had opportunities to make comments about the service and how it could be improved. A complaints procedure was in place and people told us they knew how to raise a concern if needed.

The registered manager had good oversight of the service and there was a clear ethos of care.

Staff were led by an open and accessible management team.

The unannounced inspection took place on 28 November and 2 December 2016. A previous inspection, 2 and 7 July 2015 found improvement was needed. We had found insufficient assessing and managing of day to day risks, poor infection control practices, recruitment had not been thorough, legal consent to care and treatment had not been gained, lack of respect for people, poor care planning and ineffective management. We issued requirements that the provider improve in these areas. The provider sent us a comprehensive action plan. This inspection found a lot of improvement but people remained at risk from hazards which should have been managed.

Granada House is a residential home providing care and accommodation for a maximum of 13 older people, some who have enduring mental health illness, learning disability, dementia and complex health conditions. There were 12 people using the service at the time of the inspection.

There was 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 2008 and associated Regulations about how the service is run.

Individual risks were understood and there were detailed plans in place where a risk was identified. Some risk assessment was a work in progress. These assessments were being coordinated with the updating of audit tools and were expanding the overview of where risk might exist. However, during our inspection people were at serious risk of harm from uncovered radiators, which were extremely hot. The risk had not been identified or managed until we spoke with the registered and deputy manager about it. Following the inspection visit it was confirmed that each person had this risk assessed and radiator covers were being installed to remove the risk from 21 December 2016.

Although staff were responsive to people’s everyday needs they had not recognised that the change in weather had left parts of the home cold. Neither had they responded adequately when one person had told them they were cold. The registered manager was arranging additional heating for people by the end of the inspection and people were regularly asked if they were warm enough.

The premises was clean, staff used protective clothing to reduce the risk of cross contamination and areas of the premises which had required upgrading for safety, had been made safe.

People said they were happy living at Granada House and that the care they received was good. People were supported to live in the way they wanted to. Their care needs were well met. Any health care support people needed was well provided because the staff worked closely with health care professionals, who said the care workers knew people very well. They had no concerns.

People’s safety was protected through the recruitment arrangements of staff, through which back ground checks were completed before new staff were employed. There were sufficient numbers of staff for the number and needs of people using the service and staffing was flexible. Staff received training that equipped them for their work and they received regular supervision and a yearly appraisal. Staff felt well supported and said they could take any concern or question to the registered or deputy manager.

Medicines were managed in a safe way for people. People were protected from abuse because the staff understood what to do if they saw anything which concerned them. People said they had no concerns and had no need to make any complaints. A complaints procedure was available for their use.

People were treated with kindness. People said the staff were kind and helpful one commenting, “I love this home. All the staff are very pleasant, friendly and helpful”. People said they were treated with respect and their privacy was upheld. There was friendly banter and when on

11 people lived in the home on the day of our inspection. We were given a tour of the home and spoke with five people who lived in the home. They told us they "like where they live" and staff were "nice." We spoke with four members of staff. We read the care records of four people who lived in the home. We inspected the policies and procedures, the record of complaints and the records which included details of safeguarding referrals. We read the reports from quality monitoring visits. We observed staffs' interactions with people they were supporting.

A single adult social care inspector carried out the inspection. The focus of the inspection was to answer five questions: Is the service safe, effective, caring, responsive and well-led?

Is the service safe?

Staff told us they had received training about safeguarding vulnerable people. They told us they would report concerns immediately to a senior staff member. Policies, procedures and local guidelines were available for staff to follow.

We saw that staff had a good rapport and interacted well with the people living in the home. This included our observation of people confidently and freely approaching members of staff when they wanted support.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS), which applies to care homes. The provider had policies and procedures in relation to the Mental Capacity Act (MCA) authorisations in place. This meant that people would be safeguarded as required. We saw systems in place to ensure that the manager and staff learnt from accidents as well as comments received from people who use the service.

Is the service effective?

People's health and care needs were assessed but we found they had not been supported to be involved with their care plans. We saw involvement from external health professionals would be requested, as required, for example, the community mental health team (CMHT). A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

We spoke with staff who told us that the induction training for their role had been thorough. They also told us they received regular supervision. The records we reviewed identified that not all staff had received their annual appraisals. A senior member of staff told us arrangements were in place for all staff to receive their annual appraisal.

Is the service caring?

We spoke with staff, and observed the interactions they had with people. We found, without exception, that staff spoke kindly and demonstrated a good understanding of people's needs. Staff said they enjoyed working at the home as it felt "homely" and "friendly."

During our visit we observed there was a relaxed atmosphere with people choosing where they wished to spend their time. We observed staff treating people with kindness and patience. Staff demonstrated they knew people's needs and ensured people were treated with privacy and dignity.

We saw people freely expressing what they wanted to do during the day, and they were supported by kind and reassuring staff. People told us staff were "nice" and they "can't fault them."

Is the service responsive?

People had their needs assessed on a regular basis and had been allocated a key worker. However, we found no evidence within the records read of key worker's involvement with people who used the service. A key worker is a designated member of care staff with specific responsibility for a named person who lives in the home.

Staff told us that some people had difficulty communicating although they understood what was said. Staff told us people were able to respond through various means which included the use of signs and gestures.

Is the service well-led?

We saw that people were asked for their feedback. We saw the responses from people which identified no issues or concerns. People said they liked their home and were supported to review their care plans. We saw evidence of recreational activities for people in the afternoon and some people accessed the community with a "buddy" which was funded by an external support authority.

The service's monitoring system was not fully effective and we found no audits to assess the quality of the service provided. We observed good relationship between staff and management on the day of our visit. Staff were clear about their roles and responsibilities and told us they were supported by their manager.

People we spoke with said before they received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. We were told “Staff always check what I want and never make me do anything against my wishes”. Care plan records showed that where people did not have the mental capacity to give consent the provider acted in accordance with legal requirements.

People told us they were happy with the care provided. We were told “I’m very happy living here” and “Staff usually come pretty quickly”. We found recreational activities were organised for people in the home. However, people who had no family or other contacts said they were seldom given an opportunity to go out.

We checked supplies of medication and found all were stored appropriately and were within the use by dates stated on the labels. All staff who administered medication had received training in safe handling of medicines.

On the day of our inspection we observed sufficient staff were available to meet people's routine care needs. We were told the provider regularly reviewed the staffing levels.

People spoken with said they would speak with staff if they were unhappy with any aspect of their care. One person said “Staff don’t always come up trumps but they are pretty good and try to sort things out”. Everyone said the deputy manager was very approachable and did their best to resolve any issues.

At our last inspection on 6 June 2012 we found that the provider was non compliant with four of the essential standards of quality and safety. This inspection was to review the service and to check whether improvements had been made.

We spoke with five of the people who lived in the home and observed the care provided to others who were unable to communicate verbally with us. People told us “There are some exceptional staff and the others are alright” and “Staff do their very best for me”. We observed that staff treated people who lived in the home with dignity and respect.

When we last inspected we found that people were potentially at risk from unsafe or unsuitable premises. At this inspection we found that improvements had been made and necessary repairs and maintenance work had been carried out.

The home’s manager post was vacant and a new deputy manager was in day to day charge. People said the deputy manager worked hard to maintain good quality services. One person said the deputy manager was “On the ball and they do what they can for the residents”. We found that improved staff support and supervision arrangements had also been put in place.

We looked at the minutes of the last residents meeting. Topics included activities and entertainment, meal choices, comments on rooms and fire evacuation drills. The minutes showed that the people who lived in the home were asked for their views and that this was acted on.

We spoke with eight of the people who lived in the home and two visiting relatives.

People told us that they could make decisions about their personal care and daily living choices such as when they got up and went to bed. Most people had lived in the home for a long time and said the staff knew their likes and dislikes. We were told “The staff pretty well know what I like” and “The manager will listen if you ask her for anything”.

In general most people told us they were satisfied with the service but some shortfalls were identified. People told us “We’re looked after pretty well” and “I’m happy enough here”. However, another person said “There’s nothing terrible here but it’s not an ideal situation at all”. People told us they were treated properly by most of the staff but there were some reservations. One of the people who lived in the home said “All of the carers are very good and very kind. No one has ever been disrespectful to me”. But some people said they were not always shown consideration and respect. One person said about a member of staff “They are a bit bossy. They have been here a long time and they let you know it”. Another person said “Some staff are very good, most are OK and some but not many are not very good”.

People told us that the staff were always busy. We were told “They come pretty quickly when needed, they do the best they can”. One person said “Some carers you can talk to but others are in and out in a flash. People told us that staff were good at calling their GP when they were unwell. One person said “If anything is wrong they soon get me into hospital to have a check up”. Another person who was not feeling well told us “The staff are doing all they can for me”.

People were able to be independent and involved in the community. One person said “I go out shopping and into town on my own whenever I want”. Several people told us they were visited regularly by their relatives who took them for trips into the local community. The provider also organised trips out to the beach and to other events.

We found that people’s rooms were adequately maintained but we had some concerns about the suitability of other parts of the premises.

We met and talked to five people who used the service and they told us that they felt included in decisions about their care.

People told us that they felt safe at the home and that staff “are kind".

People told us that the food was 'good' and that there was plenty to eat at times that suited them. There was assistance for them to maintain their personal hygiene and that their privacy and dignity was respected. People told us that their rooms were warm and comfortable.

We undertook an unannounced inspection of Granada House over two days on 02 and 07 July 2015. At the time of our inspection 11 people were living in the home. Granada House is a small care home providing personal care for up to 13 people.

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 2008 and associated Regulations about how the service is run. The registered manager was also a registered manager for another location, and left much of the day to day running of Granada House to the deputy manager.

At our last inspection on 01 September 2014 Granada House was non-compliant with two Regulations; care and welfare of people who use services (Regulation 9) and assessing and monitoring the quality of service provision (Regulation 10). Regulation 9 of the Health and Social Care Act 2008 Regulations 2010, corresponds to Regulation 9 of the Health and Social Care Act 2008 Regulations (2014). Regulation 10 of the Health and Social Care Act 2008 Regulations 2010, corresponds to Regulation 17 of the Health and Social Care Act 2008 Regulations (2014). We did not see the required improvements had been made.

Systems to assess the quality of the service provided in the home were not effective. The systems had not ensured that people were protected against some key risks, such as inappropriate or unsafe care and support, and had failed to identify where there was poor service delivery which affected the health and welfare of people. We did not see any action plans to address these issues.

People were not protected from the risk of harm. When risks had been identified in people’s assessments, plans were not always in place to reduce the risk. Where risk assessments were in place they did not always have suitable measures in place to manage the risk and reduce the likelihood of further incidents and harm occurring.

Care records showed the principles of the Mental Capacity Act 2005 Code of Practice had not been used because there were no capacity assessments for assessing an individual’s ability to make a particular decision. Staff were not able to tell us why the Mental Capacity Act 2005, (MCA) Deprivation of Liberty Safeguards (DoLS) or Best Interest decisions were important. The registered manager assured us staff would receive refresher training and will ask that the principles of the MCA and DOLS be explained in layman’s terms so everyone will understand what this means in practice.

Care plans did not always contain specific information about the support required to meet people’s individual needs. For example, where people exhibited behaviours which challenged others, there was nothing in place to guide staff what may trigger this behaviour and how they should support the person.

People using the service told us they were given their medication by staff at regular times. They said, “Staff leave my tablets, they know and trust me to take them”, “Staff bring me my tablets and I insist they stay with me while I take them”; “At night staff keep me company until late when they give me my sleeping tablets.” Medicines were stored safely and records were kept appropriately.

A robust recruitment procedure was not in place to ensure people were supported by staff with the appropriate experience and character. Staff told us they were not able to work with people until the appropriate pre-employment checks had been undertaken. However, we looked at staff files to ensure the appropriate checks had been carried out before staff worked with people and found they had not.

All staff said they would be confident to speak to the registered manager if they had any concerns. All staff we spoke with told us they were well supported by the registered manager of the home. Staff received regular supervision and appraisal from their manager. These processes gave staff an opportunity to discuss their performance and identify any further training they required.

We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We are considering what action to take and will produce a report later.