We undertook an unannounced inspection of The Granary Care Centre on 5 and 6 February 2018.

At the last comprehensive inspection of the service in October 2016 five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were identified and the service was rated as Requires Improvement.

After this inspection two warning notices were issued in regards to breaches of Regulation 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. A focused inspection was conducted in March 2017 to check the service was now meeting these regulations. The service was found to be compliant in these regulations.

We also conducted a focused inspection in August 2017. This was in relation to concerns we had received in regards to people’s safety in one area of the service called, Crofters Lodge. Crofters Lodge could provide treatment for up to 18 people detained under the Mental Health Act 1983. We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. After this inspection the service closed this aspect of the service in December 2017.

During this inspection we checked that the provider was meeting the legal requirements of the regulations they had breached. You can read the report from our last comprehensive inspection, by selecting the 'All reports' link for The Granary Care Centre, on our website at www.cqc.org.uk

The Granary Care Centre 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 Granary Care Centre at this time provides care and support to 60 older people who are living with dementia. At the time of our inspection there were 45 people living at the service.

The service provides accommodation in a purpose built premises. The service is over two floors. The first floor provides residential care in three units. The second floor provides nursing care in three units. The ground floor has an atrium area where activities are held and is a space for people to socialise and utilise. There is access to a secure, level garden.

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 service had met their action plan in regards to regulations they had previously breached. People, staff and relatives told us about the improvements made at the service.

At this inspection we found some areas that still required improvement in relation to accurate guidance, record keeping and reporting. Medicine documentation was not consistently safe as topical medicines records did not give clear guidance to staff and had not been consistently completed. Daily records had not been consistently completed to maintain an accurate record for people. We found some notifications in regards to Deprivation of Liberty Safeguards had not been submitted to the Commission.

Numbers of staff were kept at the assessed level deemed safe by the provider. The feedback we received was that staffing had improved. There was still a high use of agency staff acknowledged by the provider. However, steps were being taken in reducing the use of agency staff and systems had been implemented to ensure agency staff had the information they required to support people effectively.

The service operated safe recruitment procedures. Assessment identified risks to people. Guidance was in place to direct staff in how to manage risks to people whilst enabling people to remain independent. Regular checks of the environment, equipment and fire systems were completed. St

The Granary Care Centre is a service which provides personal and nursing care for up to 78 people who are living with dementia. Within The Granary Care Centre is a unit called Crofters Lodge for people with complex needs. Crofters Lodge can provide treatment for up to 18 people detained under the Mental Health Act 1983. At the time of our inspection seven people were living at Crofters Lodge.

At the last comprehensive inspection on 10, 11 and 13 October 2016, the service was rated Requires Improvement.

This responsive focused unannounced inspection on 21 August 2017 was prompted by information of concern. We had received information about people’s safety within Crofters Lodge. This included information relating to staff training, staffing levels, record keeping, risk assessments and care planning. This inspection focused only on Crofters Lodge. This report only covers our findings in relation to this area. You can read the report from our last comprehensive and focused inspections, by selecting the 'All reports' link for ‘The Granary Care Centre’ on our website at www.cqc.org.uk

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. Each manager was responsible for a number of services.

At this inspection we found the service remained Requires Improvement.

Staffing levels at the service were not always adequate and fell below what the provider had deemed safe. People were also supported by agency staff who could be unfamiliar with people’s individual needs.

Personal evacuation plans were in place but were not always accurate and up to date. These records which could be used in the event of an emergency contained different information and duplicate copies.

Risk assessments were completed and were being updated by the provider to ensure they were reflective of people’s assessed needs. The environment and equipment viewed during the inspection was safe.

We found two 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 this report.

Further information is in the detailed findings below.

This inspection took place on 14 March 2017 and was unannounced. It was carried out by one adult social care inspector and two mental health inspectors.

The Granary Care Centre is a care home providing care for up to 78 people living with dementia. Within the home there is a unit called Crofter’s Lodge for people with complex needs. Crofter’s Lodge can provide treatment for people detained under the Mental Health Act 1983. The Granary comprises two floors, the first floor is for residential care and the second floor is for nursing care.

The home is purpose built and all bedrooms are for single occupancy. During our inspection there were 14 people living on the first floor and 21 people living on the second floor in The Granary and seven people living in Crofter’s Lodge.

There was not 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. There was a temporary manager in post and they were managing the service until a permanent manager was recruited. The director of residential and nursing services told us they were in the process of recruiting a manager for The Granary and they had recruited a new manager for Crofter’s Lodge.

We carried out an unannounced comprehensive inspection of this service on 10, 11 and 13 October 2016. Breaches of legal requirements were found because the service was failing to assess some risks to the health and safety of service users who were receiving care or treatment. Authorisation was not always sought around changing medicines where this was a legal requirement. Complete and contemporaneous records were not kept in respect of each service user, systems and processes were not operated effectively to assess, monitor and mitigate risks.

After the comprehensive inspection, we used our enforcement powers and served two Warning Notices on the provider. These are formal notices which confirmed the provider had to meet the legal requirements by 28 February 2017.

We undertook this focused inspection to check they now met these legal requirements. This report only covers our findings in relation to these requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link on our website at www.cqc.org.uk

We found action had been taken to improve people’s safety although some areas of the service required some improvement.

The correct procedures were being followed where people who were detained under the Mental Health Act 1983 (MHA) had changes to their medicines and the correct authorisation for the changes were in place.

Risks to people were identified and measures were put in place to reduce the risks. There were effective systems in place to ensure pressure relieving mattresses were set at the correct pressure.

Improvements had been made which ensured records of the care delivered were completed. Some of the care plans needed to include clearer instructions for staff on how to support people with specific aspects of care. Staff were aware of how to support people and the manager had an action plan in place to update all of the care plans.

The systems for assessing, monitoring and improving the quality and safety of the service provided had improved.

We found the provider had made the improvements required to meet the legal requirements.

The Granary Care Centre is a care home providing care for up to 78 people living with dementia. Within the home there is a unit called Crofter’s Lodge for people with complex needs. Crofter’s Lodge can provide treatment for people detained under the Mental Health Act 1983. The Granary comprises two floors, the first floor is for residential care and the second floor is for nursing care.

The home is purpose built and all bedrooms are for single occupancy. During our inspection there were 14 people living on the first floor and 22 people living on the second floor in The Granary and eight people living in Crofter’s Lodge.

We inspected The Granary Care Centre in August 2015. At that Inspection we found the provider to be in breach of three regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The regulations included; safe care and treatment, need for consent and receiving and acting on complaints. We also completed a Mental Health Act visit inspection in Crofters Lodge on 6th January 2016.

The provider wrote to us with an action plan of improvements that would be made. They told us they would make the necessary improvements by March 2016. During this inspection we saw the improvements identified had been made. However we found further breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and the Care Quality Commission (Registration) Regulations 2009.

The inspection took place on 10, 11 and 13 October 2016 and was unannounced.

There was a manager in post but they were not registered with us. 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 manager was in the process of completing their registration application with us.

Risks to people were not always identified. Where risk assessments were in place they did not always contain accurate and up to date information. The home was not regularly assessing risks relating to people when they were granted leave from Crofters Lodge which put the safety of people at risk.

There was some information missing from records relating to how people took their medicines. Authorisation was not always sought around changing medicines where this was a legal requirement. Medicines were stored securely.

People were supported by staff who were not directly employed by the service. Relatives and staff raised concerns about the number of agency staff the home used at times to cover their vacant posts. There were times when night shifts were covered predominantly with agency staff. We saw the same agency staff were requested to work at the home to provide consistency.

There were some gaps in staff training and the manager had plans in place to address this. New members of staff received an induction which included shadowing experienced staff; they told us this prepared them for the role.

Staff did not always feel supported, listened to and valued. Staff did not always receive regular one to one supervision with their line manager. Where improvements were identified with staff performance, this was monitored and reviewed by their manager.

Care plans did not always include accurate and up to date information. Records were not always fully completed by staff.

The provider had a system in place to audit the service, whilst the audit identified some of the concerns we identified during our inspection there were areas of concern that were not covered in the audits.

The provider was not notifying us of all incidents in line with their legal responsibility.

Relatives said the home was a safe place. Systems were in place to protect people from harm and abuse and staff knew how to follow them.

A recruitment procedure was in place a

This inspection took place on 11 November 2014 and was unannounced. Our last full inspection took place in June 2013. At that time we found two breaches of regulations. We found that activities did not fully meet the needs of people living with dementia and also that staff did not receive adequate supervision and specialist training in dementia. We returned to the service in October 2013 and found that action had been taken to meet these regulations.

The Granary Care Centre provides care for people living with dementia. Within the home there is a unit called Crofter’s Lodge for people with complex needs. Crofter’s Lodge can provide treatment for people detained under the Mental Health Act 1983. At the time of our inspection there were 52 people living in the home.

There is a registered manager in place at the home. 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.

We found that the service was not always safe. At the time of our inspection there were significant staff vacancies amongst both care staff and nurses and high use of agency staff. This meant that people in the home did not benefit from the continuity of care that a stable and permanent care team would provide.

The systems in place for managing people’s medicines were safe and the administration of medicines was recorded on suitable charts. People’s medicines were stored securely.

We found there were areas of the home that required further attention to ensure people were fully protected from the risks of cross infection.

People were not able to speak with us directly about how safe they felt in the home. However people appeared settled and at ease in the presence of staff. Staff had received training in safeguarding adults and demonstrated awareness of their responsibilities to protect people from the possibility of abuse.

Staff told us they were well supported in their role and received regular supervision and training. This included training in key areas such as moving and handling, fire safety and safeguarding adults. Staff commented on positive changes that had occurred in the home as a result of recent specialist training in dementia.

Staff were aware of the Mental Capacity Act 2005 and in some cases had applied the principles to decision making on behalf of people who weren’t able to make the decision for themselves. However we also saw examples of where relatives had provided consent to the use of bedrails. This was not in line with the principles of the Act and did not demonstrate that the person’s best interests had been considered or a less restrictive option sought.

People were protected against the risks of malnutrition because their weight was monitored and action taken when concerns were identified. We saw evidence that the advice of healthcare professionals was sought when necessary. For example we saw that guidance provided by dieticians and speech and language therapists was kept on file and people could see their GP when necessary.

People in the home did experience staff that were caring and considerate in their approach, however this was not consistent. We saw some occasions where staff interacted with people in a way that was not respectful and considerate of the person’s feelings.

When people weren’t able to discuss their views on the care they received, relatives and representatives were included where possible. Staff took account of the person’s views by interpreting their behaviours and actions as an indication of their wishes.

We saw examples where people were being cared for in a way that was fulfilling and met their personal wishes. However, not everyone received care that met their individual needs. There were activities available in the home but not all staff supported people to be engaged with these. This meant people experienced significant amounts of time when they were not supported to be involved in activities that reflected their individual interests.

There were systems in place to monitor the home’s performance and this included monitoring accidents and incidents within the home to identify any trends and take action accordingly. However, we identified breaches of regulation during our inspection and this meant that quality monitoring processes were not fully effective in identifying concerns.

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

This inspection took place in order to follow up concerns found at our previous inspection in June 2013. We found that activities provided for people did not reflect best practice or guidance in relation to dementia care. Staff did not always receive regular supervision and not all had received basic training in dementia care. When we returned to the service in October 2013, we found that improvements had been made.

We spoke with staff and relatives and made observations of the care that people were receiving. Relatives that we spoke with were happy with the care provided at the home and we observed interactions where staff were kind and caring. Staff appeared knowledgeable about the kinds of activities that people enjoyed and engaged in and we saw that some recordings were made about the activities undertaken.

We viewed information relating to training for staff and saw that all staff had completed basic dementia training. Staff were positive about the course and told us about the things they had learnt from it. Senior staff were due to attend further in depth training. We viewed a sample of supervision records and saw that these were used to discuss staff development needs.

We visited The Granary Care Centre as part of our planned programme of inspections. Action had been taken in response to some shortcomings that had been found at previous inspections. Overall however we found there were concerns about the quality of care and support that people experienced. More needed to be done to ensure that risks to people’s safety and wellbeing were reduced.

We judged that the staffing arrangements were a significant factor in relation to these concerns. There were not enough staff to ensure that people's needs were consistently met. The training plan for the staff team did not reflect the specialist nature of the service. This meant that people were at risk of receiving care from staff who lacked the skills and support that they needed to do their jobs well.

Some systems were in place for quality assurance. However we found that these were not effective in ensuring that good standards were maintained throughout the service.

We had received information which raised questions about the care and support that people received and the arrangements being made for their safety. In response to this information we made an unannounced visit to The Granary. We spent time observing people’s interactions with staff and we looked at arrangements in the home. This helped us to make judgements about the service and the outcomes that people experienced. The part of The Granary Care Centre known as Crofter’s Lodge was not inspected on this occasion.

Systems were in place for planning people's care although we found that these were not always being effectively implemented. We observed occasions when staff engaged well with people. However we also saw support being provided in ways which lacked an individual and person centred approach.

Staff told us that they received training in ‘safeguarding’ people and knew what to do if they had any concerns. We found however that although procedures were in place, these were not wholly effective in reducing risks and incidents which had an impact on people’s wellbeing.

A relative described the staff as “always cheerful and happy”. We found that the people who use the service would benefit from a more consistent level of staffing throughout the week.

The inspection took place on 27 August and 2 September 2015 and was unannounced.

We inspected The Granary Care Centre in November 2014. At that Inspection we found provider to be in breach of four regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. The regulations included care and welfare of service users, assessing and monitoring the quality of service provision, respecting and involving service users and consent to care and treatment. These correspond to regulations 9 person centred care, 10 dignity and respect, 17 good governance and 11 need for consent of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider wrote to us with an action plan of improvements that would be made. They told us they would make the necessary improvements by May 2015.During this inspection we saw some of the improvements identified had been made.

The Granary Care Centre is a care home providing care for up to 78 people living with dementia. Within the home there is a unit called Crofter’s Lodge for people with complex needs. Crofter’s Lodge can provide treatment for people detained under the Mental Health Act 1983. The home is purpose built and all bedrooms are for single occupancy. During our inspection there were 48 people in The Granary and 11 people living in Crofter’s Lodge.

There were two project managers in post; the project managers were responsible for managing the home in the absence of an appointed home manager. There was no manager in post registered with the Care Quality Commission. 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. There had not been a registered manager since March 2015.

Relatives and staff raised concerns over the changes of management and lack of leadership in the home.

People were supported by staff who were not directly employed by the service. Relatives and staff raised concerns about the amount of agency staff the home used to cover their vacant posts. There were times when shifts were covered predominantly with agency staff. The project manager told us they had recently recruited new staff to fill some of their vacant post and they used regular agency to aid consistency.

There were systems in place to protect people from abuse; however we found these were not always effective. Some permanent staff were not able to tell us where they would report whistleblowing concerns to if they needed to go outside of the organisation. People who use the service appeared calm and relaxed during our visit, with one person commenting “I am safe enough here”. Relatives told us they thought their family members were safe. Staff were able to recognise signs of abuse and felt confident in reporting it to the managers or team leader

Medicines were not always administered safely due to staff not ensuring they followed infection control guidelines and washed their hands. There were appropriate systems in place for the storage of medicines and accurate records were maintained.

We found people’s rights were not fully protected as the manager had not always followed correct procedures where people lacked capacity to make decisions for themselves.

People had individual care plans. There was information missing from some of the care plans. The managers were in the process of auditing the care plans to identify where they required improvement .The managers had a plan in place to introduce a new care planning format to provide a more person centred approach.

There was a process in place to raise complaints about the service. Where complaints had been raised the complainant did not always receive information relating to the outcome of their concerns.

A recruitment procedure was in place and staff received the appropriate pre-employment checks before starting work with the service. Staff received appropriate training to understand their role and they completed training to ensure the care and support provided to people was safe. New members of staff received an induction which included shadowing experienced staff before working independently.

People commented positively about the food provided. One relative raised concerns about the quality of the food and another said they thought there was nothing to complain about. People had access to food and drinks throughout the day and where people required specialised diets these were prepared appropriately.

People and their relatives told us they were happy with the care they or their relative received at The Granary Care Centre. One person told us “They are kind and lovely.” A relative told us “Staff know what they are doing.”

The manager and senior management had systems in place to monitor the quality of the service provided. Audits covered a number of different areas such the environment, infection control and medicines.

We found 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.