Rothsay 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.

There was a registered manager in post. A registered manager 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.

Rothsay Grange provides care and accommodation for up to 60 people who have dementia and / or health conditions. When we inspected there were 34 people living in the home.

The home was purpose built, spacious and equipped to meet the needs of people living there. There were extensive grounds that could be accessed by some people to the front of the premises and a large courtyard garden accessible to all residents.

At the last inspection of this service on 31 March and 1 April 2017 we rated the service as ‘Requires Improvement’. This was due to there still being insufficient staffing deployed to meet the needs of people living in the home and improvements needed in quality audits and responses to complaints. We found at this inspection that improvements had been made in all previous areas of concern and the service had achieved an overall rating of ‘Good’.

There were systems in place to keep people safe and staff had completed training in safeguarding.

A robust recruitment process ensured that only people suitable and qualified to work in a caring role were employed at the service.

Medicines were safely managed. Nurses administering medicines were protected from interruptions during the medicines round.

Staff asked for consent before providing care and understood the Mental Capacity Act (2005) and supported people with decisions if they lacked capacity to make them independently.

Appropriate applications were made to the local authority to deprive people of their liberty.

People were supported with their nutrition and hydration needs, referrals to appropriate healthcare professionals were made and care plans developed to prevent malnutrition.

Staff enabled people to maintain their dignity and provided respectful and empathetic care.

Care plans were person-centred and involved people and their families. These were regularly reviewed and updated according to the changing needs of individuals. Peoples personal histories were in depth and contained contacts for important friends and relatives.

Care was also person-centred. Some people liked staff to be informal and jocular when supporting them, others liked a more formal approach. Staff ensured they addressed people by their preferred name and took the approach requested by them.

End of life care plans were holistic and included details of people’s spiritual needs.

The registered manager and provider completed regular audits to ensure the service was providing safe and good quality care. If there were areas requiring improvement the registered manager worked with the staff team to make improvements.

We previously inspected Rothsay Grange on the 18 and 19 July 2016. We had significant concerns about the quality of care people received. The provider was in breach of Regulation 18 Registration Regulations 2009: Notifications of other incidents, Regulation 11 of the HSCA: Consent, Regulation 16 of the HSCA: Receiving and acting on complaints, Regulation 17 of the HSCA: Good Governance, Regulation 19 of the HSCA: Fit and proper persons employed and Regulation 18 of the HSCA: Staffing. We also took enforcement action and issued a warning notice in relation to Regulation 12 of the HSCA: Safe care and treatment.

Staff were not always appropriately deployed, recruitment checks were not robust, arrangements for communicating risk were not effective, medicines were not managed safely, staff did not receive good support and supervision and good systems were not being applied to support people to make decisions. We also found care was not always personalised, end of life care was not effective and people were not supported to manage their pain. Safeguarding concerns were not always reported to the relevant professional organisations. Leadership was inconsistent and quality assurance systems were not effective.

Rothsay Grange provides accommodation and support for up to 60 people who may require nursing and dementia care. At the time of our inspection 35 people were living at the home. The home consisted of three floors. The middle floor, known as Memory Lane, cared for people living with dementia. The ground floor accommodated people with personal care needs. The top floor accommodated people requiring re-ablement and respite care, some of whom had long term care needs.

At this inspection we found significant improvements had been made in many areas. The provider had met five of the six requirements we issued and had taken sufficient steps to meet the warning notice.

However the deployment of staff still requires improvement to ensure people’s needs are met at all times and some relatives told us they were not always satisfied with how their complaints were dealt with. They told us they did not always receive updates when they requested feedback.

Robust recruitment procedures were in place and followed to assess the suitability of staff to work with people.

Good arrangements for the management of people’s medicines were in place. The registered manager had good systems in place to identify any errors and appropriate action was taken when this happened.

Safeguarding concerns were reported appropriately to the local authority and CQC.

Communicating risk relating to particular conditions and behaviours was discussed through effective handover meetings and shared with relevant staff.

The provider had complied with the requirements of the Mental Capacity Act 2005.

Staff at all levels received appropriate support, supervision and competency assessments. Staff had completed training relevant to their role with input from external organisations where appropriate.

People who were at risk of dehydration or malnutrition were monitored effectively. Food and fluid intake records were reviewed daily by the nursing staff and management to check people’s intake.

Guidance was in place to help people manage their pain. Records provided good detail for to use when assessing whether someone was in pain.

People who were at risk of skin damage were supported properly, in line with their care plan and investigations into why skin damage occurred were conducted.

Actions identified through internal quality assurance audits were followed up and closely monitored.

Leadership within the home was open, supportive and transparent.

Relatives, healthcare professionals and people consistently told us staff at all levels were caring.

Documentation detailed information about people’s likes, dislikes, hobbies and interests. Records also provided detail about people’s past including previous jobs, their religious views and different c

We previously inspected Rothsay Grange on 9 and 13 April 2015 where we identified three breaches of the Health and Social Care Act 2008. We found people had not been protected from the risks of inappropriate care and support, because the provider’s recruitment procedures did not effectively ensure applicants were of good character. People were at risk of receiving inappropriate care, because the provider had not deployed sufficient numbers of staff to meet people’s needs. We also found people were not supported through the operation of effective systems and processes to assess, monitor and mitigate risks to their health and welfare.

Rothsay Grange provides accommodation and support for up to 60 people who may require nursing and dementia care. At the time of our inspection 49 people were using the service. The home consisted of three floors. The middle floor, known as Memory Lane, cared for people living with dementia. The ground floor accommodated people with personal care needs. The top floor accommodated people requiring re-ablement and respite care, some of whom had long term care needs.

At this inspection we returned to assess whether the provider had made the necessary improvements from our last inspection and to check they met our requirements. We also inspected Rothsay Grange at this time because we had received a number of concerns from relatives and healthcare professionals. They told us people were not receiving the appropriate end of life care and said staff were still not appropriately deployed throughout the home. They told us people were not being supported to look after their skin and said risk assessments and care plans did not always provide staff with robust guidance. We were told of concerns that the leadership in the home was not effective and we were told medicines were not being managed safely or administered at the times people needed them. We were also advised care plans were not in place to assist people who were in pain.

Although some improvements had been made in respect of recruitment and quality assurance, the provider had failed to meet the requirements issued at the last inspection. In addition we identified significant concerns relating to the care and support people received.

The provider did not have sufficient numbers of suitably skilled, qualified and experienced staff deployed at all times to meet people’s care and support needs Staff consistently told us they found it difficult to meet people’s needs and relatives told us they felt staffing levels were unsafe.

Robust recruitment procedures were not always fully applied.

Arrangements for the management of people’s medicines were not always safe.

Safeguarding concerns were not always reported appropriately to the local authority or to CQC. People told us complaints were not always taken seriously or appropriately investigated.

Communicating risk relating to particular conditions and behaviours that challenged others were not always shared effectively. Staff were not consistently provided with good guidance on how to respond to people’s needs.

The provider failed to ensure people’s freedoms were not unlawfully restricted and documentation did not consistently reflect the requirements of the Mental Capacity Act 2005.

Staff at all levels did not consistently receive appropriate support, supervision or competency assessment.

Staff had not always completed training relevant to their role.

People who were at risk of dehydration or malnutrition were not always monitored effectively. Food and fluid intake records were often incomplete.

Assessments and guidance were not in place to help people manage their pain. It was unclear how staff assessed when people were in pain.

People who were ar risk of skin damage were not always supported properly and investigations into why skin damage occurred were not consistently conducted. There was no evidence of action taken to reduce the chance of skin damage happening again.

People’s

The inspection team consisted of an adult social care inspector. On the day of our inspection 30 people used the service. We spoke with four people who use the service and two people’s relatives, and four members of care staff including nurses and care workers, some of whom worked for an agency. We also spoke with the operations manager who was managing the service at the time of our inspection.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time. The service was in the process of advertising for a new registered manager.

We observed how staff supported people, and looked at documents including care plans and management reports. People were cared for in units across three floors, depending on the level and type of their needs. For example, staff on one floor cared for people who required nursing care, and on the memory unit they supported people with dementia. This helped to ensure people were provided with care appropriate to their needs.

Information of concern had been brought to our attention regarding staffing levels, and the impact of this on meeting people’s needs. We considered this concern as part of our inspection. We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask; is the service caring, responsive, safe, effective and well led?

This is a summary of what we found.

Is the service caring?

The service was caring. We observed that staff were kind and patient. A relative told us “The best thing [about the service] is the carers. Some are absolute treasures”. We saw staff supported people at their pace when helping them to mobilise and eat. They spoke gently with people, and provided reassurance when they were anxious. An agency care worker told us “Staff have a good relationship with people. They hug them like they are family”.

Is the service responsive?

The service was responsive to people’s needs. We noted that call bells were answered promptly during our inspection, and when people asked for help during mealtimes staff were quick to respond to their requests. One person told us “Staff are willing to help in any way they can, they never grumble. Most of the staff are very nice”.

People’s care plans documented that changes to people’s needs or health had been identified. We saw that referrals to health professionals had been made when required. Care plans included guidance for staff to ensure they understood how to support people in accordance with instructions from health professionals.

Is the service safe?

One person told us “I feel secure here”. Risks affecting people and others had been assessed, and regularly reviewed. This helped to ensure that people were protected from potentially harmful hazards. We noted that staff had been trained in safe procedures to use when supporting people to mobilise and re-position. The operations manager explained that staff competencies were assessed during an induction period to ensure they had the skills required to support people safely.

Concerns had been raised with CQC regarding insufficient staffing levels, and the impact this had on attending to people’s needs. We observed staffing levels during our inspection, and reviewed rotas for the previous two months. The operations manager told us staffing levels had recently been increased, and we saw this reflected in the rotas we looked at. We did not observe delays in attending to people during our inspection. One nurse told us “They are getting there with staffing. Call bells are managed better now”.

Is the service effective?

The service did not always effectively document that people had consented to elements of their care, such as taking medication or receiving vaccinations. We saw that mental capacity assessments had been clearly documented for some people, and indicated whether these people were able to make an informed decision about specific elements of their care or treatment. But for other people, we saw that a best interest decision had been made on their behalf without evidence of an assessment of their capacity to make the decision first. This demonstrated that decisions may have been made on people's behalf without consideration of the legal process to do so.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to gaining people’s consent to care and treatment.

We found that the service effectively managed people’s care and treatment. Assessments ensured that changes to people’s nutritional balance, skin integrity, mental wellbeing and mobility were identified promptly. When changes had been identified, we saw that staff took appropriate actions to ensure people received the care or treatment required to maintain their health and promote their wellbeing.

New staff attended an induction programme that ensured they had the skills and confidence required to support people effectively. The provider’s mandatory training programme ensured that these skills were maintained and refreshed. However, we did not find that staff received regular supervision or annual appraisal meetings, in accordance with the provider’s policy. This meant staff did not always have a formal opportunity to discuss concerns or development on a one to one basis.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to supporting staff.

Is the service well led?

The service was well led. One staff member described the current management arrangements provided by the operations manager as “responsive", and told us the manager was "willing to meet and listen”. They had been in place for one week at the time of our inspection. The manager told us of their plans to improve people’s care and welfare, and provide more support for staff. We noted that the time planned in which to achieve this was focused and constrained to ensure these changes delivered the required results promptly.

Rothsay Grange is a care home providing accommodation, care and nursing support for up to 60 people. At the time of our visit 30 people were living there.

The home is divided into three floors:

• The ground floor accommodates people who are physically frail, some of whom may be living with dementia. At the time of our visit 13 people were living on this floor.
• The first floor is called the ‘Memory Lane Community.’ This unit provides support and accommodation for people living with dementia. At the time of our visit 12 people were living on this floor.
• The second floor currently accommodates five people with a wide range of health and care needs.

The service has a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service and who shares the legal responsibility of meeting the requirements of the law with the provider.

People we spoke with said the staff were kind and caring. We observed that staff assisted people with their care in an unhurried manner and saw that people’s privacy was respected.

Although most people were happy with the care and support provided a few were concerned that staffing levels were not always sufficient and a few others felt that some staff were not trained sufficiently to meet their needs. The registered manager was aware of the concerns and was monitoring staffing levels. We saw that the levels determined to be safe had been maintained. The registered manager also ensured that inexperienced staff received training and worked with staff who had more experience to ensure that people received safe care.

People’s care and treatment needs had been assessed and staff followed clear plans of care to support

them effectively. Staff consulted with external health care professionals when they needed to meet people’s specialist needs.

One person had a negative experience after they had been discharged back to the service after spending time in hospital. Their plan of care following their discharge had not been appropriate and this meant that there was a delay in them receiving further specialist medical support. We told the registered manager that improvements could be made in this area.

People were provided with information about their care and treatment and we found the service was meeting the requirements of the Deprivation of Liberty Safeguards, with systems in place to protect people’s rights under the Mental Capacity Act 2005.

The management structure of the home gave clear lines of responsibility and accountability. There were good quality monitoring systems in place which helped to ensure that the service continued to achieve its aims and objectives.

We had formally warned this service that they needed to make improvements in relation to the care and welfare of people. This specifically related to wound care. We had also formally warned this service that they needed to make improvements in relation to record keeping. We carried out this visit to ensure that improvements had been made.

We found that the care and welfare of people in relation to their wound care had improved since our last inspection. Record keeping had also improved and therefore the provider had met both of these requirements.

However we found that where people may not have the capacity to consent, the provider had not always acted in accordance with legal requirements.

Although care planning had improved since our last visit, it was still unclear about how the service provided care and support for all people who were distressed or who may be in pain.

People told us their consent was sought prior to care being provided.

Everyone we spoke to told us they were happy with the care and support received.

People said they had the help they required and they were encouraged to be as independent as possible.

One person told us that they always got their medicines on time which was important to them.

The inspection took place on 9 and 13 April 2015 and was unannounced. Rothsay Grange provides residential and nursing care for up to 60 older people, including people living with dementia, and those requiring respite and rehabilitation support. At the time of our inspection 41 people were living in the home.

The home consisted of three floors. The middle floor, known as Memory Lane, cared for people living with dementia. The ground floor accommodated people with personal care needs. The top floor accommodated people requiring re-ablement and respite care, some of whom had long term care needs.

The home did not have a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run. The person managing the home was on leave at the time of our inspection. They were in the process of applying for the registered manager role with CQC, but subsequently left this post on 13 April 2015.

At the last inspection on 19 August 2014 we asked the provider to take action to make improvements to support staff to provide people with appropriate and skilled care, and ensure consent to care was gained following legal requirements . At this inspection we found these improvements had been made.

People were at potential risk of harm, because the provider’s recruitment procedure did not robustly meet legal requirements. Although some checks, such as identity, criminal record checks and registration with professional bodies, had been completed satisfactorily, the provider did not ensure that gaps in applicants’ employment history had been identified or investigated. Evidence of suitable conduct in previous relevant employment positions had not always been requested. There was a risk that staff employed would not be of suitable character to safely support people.

Staffing levels were not always sufficient to meet people’s identified needs. Sufficient staff numbers, identified by the provider to meet people’s needs, had not always been on duty during a four week period in March 2015. Staff had ensured this did not impact on people’s physical support, but acknowledged that they were not always able to find sufficient time to meet people’s social and emotional needs.

Checks and audits completed by staff and the manager had not always identified errors and omissions in people’s records. There was a risk that people may not receive the care and support required to ensure their health and wellbeing. Medicines audits had not been updated to record progress towards completion. The provider’s procedures had not been robustly implemented.

Staff demonstrated the provider’s values, such as encouraging people’s independence and treating people with respect. However, relatives and staff commented that the manager did not always display these values. At times they felt their concerns had been not been addressed satisfactorily, or were dismissed without consideration.

People were protected from the risk of abuse, as staff understood how to identify possible signs of abuse, and the actions required to protect people and report concerns. Risks had been identified, monitored and addressed appropriately to ensure people and others were not placed at risk of harm. Staff understood the actions required to protect people from harm and actions taken had been effective in promoting people’s health and welfare.

People received their prescribed medicines safely. Medicines were stored, administered and disposed of safely. Administration records were complete, and included guidance for staff on ‘variable’ and ‘as required’ medicine doses.

Staff were supported to ensure they had the skills, knowledge and training required to effectively meet people’s needs. Although supervisory meetings had not met the provider’s requirement for quarterly review, staff told us there were effective measures in place to provide them with the support they required to raise and discuss issues and concerns.

Staff understood the principles of the Mental Capacity Act 2005 (MCA), and followed these to ensure people were supported to give valid consent to their care. Where people were identified as lacking the mental capacity to make informed decisions about specific aspects of their care, appropriate actions had been documented to evidence that lawful consent to care was gained from those best placed to provide this.

People were supported to maintain a healthy diet. Where people were assessed to be at risk of malnutrition or dehydration, appropriate measures had been implemented to ensure people maintained a sufficient daily intake of food and fluids. People’s health needs were effectively identified, and referrals to appropriate health professionals ensured they received the care they needed.

Staff were kind, respectful and caring. People sought staff support when they were anxious or confused, and readily chatted with staff. Staff were prompt to take actions to promote and protect people’s dignity, and respected people’s privacy when they chose to be on their own.

People’s care needs had been discussed and assessed with them, or those important to them, prior to their admission to the home, and were regularly reviewed. People’s views and preferences were included in their plan of care. A range of activities were provided, and people’s engagement with these was reviewed to ensure these activities met their preferences. People were satisfied with the care they experienced, and understood the process to raise concerns or complaints.

People, and those important to them, were able to discuss their views, wishes and concerns about the home, and individual care and support, during meetings and care reviews. Their views had influenced changes to menus.

The regional director was in the process of recruiting a new management team for this home at the time of our inspection. They demonstrated the provider’s values in their approach to people and staff. The provider reviewed information such as accident and incident reports to ensure appropriate actions were implemented to reduce the risk of repetition. Learning was shared across homes to develop understanding and shared learning for all managers. This promoted improvements to the quality of care people experienced.

We found three breaches of the Health and Social Care Act 2008 (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.