This inspection took place on 28 August 2018 and was unannounced.

The Grange is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. At the time of this inspection there were five people living at the service. Some people were more independent than others and able to make their own decisions, whilst others needed support and assistance from staff to remain as independent as possible.

There was a registered manager in post who was also the registered provider and owned the service. 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 was last inspected on 23 March 2018 when the area of 'Well-led' was rated as 'Inadequate' and the overall rating was 'Requires Improvement'. At that time, we found five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Regulation 9: The provider had failed to ensure that care was planned and delivered in a person-centred way. Regulation 12: The provider had continued to fail to ensure that risks were adequately assessed and action was taken to mitigate them when possible. Regulation 13: The provider had failed to ensure that people were protected from instances of potential abuse. Regulation 17: The provider had continued to fail to establish and operate systems to assess, monitor and improve the quality of the services provided and reduce risks to people. Regulation 18: The provider had continued to fail to ensure that staff were suitably qualified, competent and skilled to carry out their roles. We also found a breach of Regulation 18 of the Registration Regulations 2009 in that the provider had failed to notify CQC of notifiable events in a timely manner.

The provider sent us an action plan dated 21 May 2018, setting out how they would improve the service to meet the Regulations.

We also made recommendations regarding making sure the service was clean and odourless and involving people in menu planning.

At this inspection, on 28 August 2018 we found improvements had been made to risk management, protecting people from potential abuse and ensuring staff had the necessary training for their roles so that these breaches of the Regulations had been met. However, we identified a breach of Regulation 10 of the Health and Social Care 2008 (Regulated Activities) Regulations 2014. There was inconsistent practice in the staff team with regards to treating people with respect and supporting them to be independent.

The provider had acted to make sure the service was clean and pleasantly smelling and to support people to be more involved in meal planning.

This will be the fourth time this service has been rated Requires Improvement.

The care service was working towards being developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.

The staff team and registered manager had attended training from an external provider on person- centred planning but its principles had not been fully embedded at the service. Staff supported people to be independent but on occasions continued to do things for people when they were able to do them for themselves.

Staff were kind and caring, but one staff member spoke to a person in a disrespectful manner during the inspection. The provider took immediate action to address this an

This inspection took place on 23 March 2018 and was unannounced.

The 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.

The Grange is a small care home for people with learning disabilities, some of whom displayed behaviours which may challenge others. The service is in the village of Beltinge, a short distance from Herne Bay. There is a communal lounge and kitchen downstairs and bedrooms are situated throughout the premises. At the time of this inspection there were five people living at the service. Some people were more independent than others and able to make their own decisions, whilst others needed support and assistance from staff to remain as independent as possible.

There was a registered manager in post, they were also the registered provider and owned the service. 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 care service had not been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service should be supported to live as ordinary a life as any citizen.

At our last inspection we found that guidance for staff was lacking and people’s care plans had not been updated to include information about their health care needs or when the support they needed to manage their behaviour changed. Activities were repetitive and people spent most of their time ‘watching tv’ ‘listening to music’ and ‘going out for a drive.’ There were no plans in place to increase people’s independence. We recommended that the provider trained staff in areas of best practice relating to supporting people with learning disabilities, including person centred planning, person centred active support and positive behaviour support. We found three breaches of the regulations regarding safe care and treatment, person-centred care and good governance.

At this inspection we found ongoing concerns. People were not supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible; the policies and systems in the service did not support this practice. Although senior staff had re-written people’s care plans, staff and the registered manager lacked knowledge and understanding regarding best practice when supporting people with learning disabilities. Staff had not received the training we recommended at our last inspection and people were not supported to be as independent as possible. Activities remained ad hoc and unplanned, and continued to be repetitive. There were no systematic plans in place to assist people to learn new skills or experience new things. Staff had not discussed with each person what they wanted to happen at the end of their lives.

Sometimes people displayed behaviour that challenged. These behaviours could result in both verbal and physical aggression towards staff and other people living at the service. Staff documented these incidents in people’s daily notes, but did not consistently complete incident forms or handover when these incidents occurred. We found instances of potential abuse documented in people’s daily notes that had not been reported to the registered manager or the local safeguarding team. After the inspection the registered manager emailed us to tell us they believed these incidents related to, ‘wording’ and were ‘not incidents.’ They had not consulted wit

This inspection took place on 01 February 2017, was unannounced and carried out by two inspectors.

The Grange is a small care home for five people with learning disabilities and some complex and challenging behavioural needs. The service is in the village of Beltinge, a short distance from Herne Bay. There is a communal lounge and kitchen downstairs and bedrooms are situated throughout the premises. There is an office upstairs. At the time of this inspection there were five people living at the service. Some people were more independent than others and able to make their own decisions, whilst others needed support and assistance from staff to remain as independent as possible. The service had its own vehicle for people to go out to the local community.

There was a registered manager working at the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service and 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.

At the last inspection in January 2016, the provider did not have sufficient guidance for staff to mitigate risks when supporting people with their behaviour, staff were not receiving ongoing supervision or appraisal to discuss their training and development needs. The systems in place were not effective to quality assure the service and environmental risk assessments had not been carried out. After the inspection the provider sent us an action plan telling us how they were going to improve.

At this inspection we found that some improvements had been made but further improvements were required. Staff were receiving supervision and appraisals to discuss their training and development needs. However, staff still lacked the guidance and detail they needed in the behavioural risk assessments to ensure that people were supported with their behaviour safely. Accidents and incidents had not been summarised to identify patterns and trends to prevent further occurrence. The provider had introduced some checks on the service but further monitoring was required to ensure that shortfalls in the service would be identified and action would be taken to make improvements. No environmental risk assessments had been completed.

Risk assessments for behaviours that challenge did not always have full guidance recorded to ensure that staff had the information they needed to make sure people were being supported consistently and safely.

The registered manager had implemented a supervision and appraisal system and all staff had received an annual appraisal. Staff told us they felt supported by the management team. There was an on-going training programme to make sure staff had the skills and knowledge to support people effectively.

There were enough trained staff on duty to meet people’s needs. Staffing was planned around people’s activities and appointments, so the staffing levels were adjusted depending on what people were doing. The registered manager made sure that there was always the right number of staff on duty to meet people’s assessed needs and they kept the staffing levels under review.

A system of recruitment checks were in place to ensure that the staff employed to support people were suitable and had the skills and experience to carry out their role.

People were protected against the risks of potential abuse. Staff had attended training about safeguarding people from harm and abuse, and the staff we spoke with knew about different types of abuse and how to raise concerns. People were protected from the risk of financial abuse as there were clear systems in place to safeguard people’s money.

The staff carried out regular health and safety checks of the environment and equipment. However, although the water temperatures had been checked to reduce the risk of scalding, the water had not

This inspection took place on 05 January 2016, was unannounced and carried out by two inspectors.

The Grange is a small care home for five people with learning disabilities and some complex and challenging behavioural needs. The service is in the village of Beltinge, a short distance from Herne Bay. There is a communal lounge and kitchen downstairs and bedrooms are situated throughout the premises. There is an office upstairs. At the time of this inspection there were four people living at the service. Some people were more independent than others and able to make their own decisions, whilst others needed support and assistance from staff to remain as independent as possible.

There was registered manager working at the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service and 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.

Safeguarding procedures were in place to keep people safe from harm. However, there had been a recent incident which had not been reported to the local authority safeguarding team. We discussed this with the registered manager who told us that this would be processed without delay. People told us they felt safe at the service and were able to tell staff if they had any concerns or something was wrong. All staff had been trained in safeguarding adults, and discussions with them confirmed that they knew what action to take in the event of any suspicion of abuse. Staff knew about the whistle blowing policy and were confident they could raise any concerns with the registered manager, or outside agencies if necessary.

Risks to people were identified and measures to reduce the risks were in place. However, some risk assessments for behaviours that challenge did not always have full guidance recorded to ensure that staff had the information they needed to make sure people were being supported consistently and safely. This left people at risk of not receiving the support they needed to keep them as safe as possible. Accidents and incidents were recorded but had not been summarised to identify if there were any patterns or if lessons could be learned to support people more effectively to ensure their safety.

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards. The registered manager showed that they understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). Authorisations to restrict some people’s liberty were in place and guidelines were being followed to ensure this was being carried out in the least restrictive way.

The registered manager worked alongside the staff on a daily basis but there was a lack of regular one to one meetings with staff and there was no evidence to show that staff had received an appraisal to give them the opportunity to discuss their training and development needs. The registered manager told us that there had been a recent staff meeting but there were no minutes of the meeting available to confirm this had taken place.

Staff had received a range of training and were in the process of updating the required courses. Most of the staff had worked in the service for some considerable time and there had only been one recent staff addition, who was in the process of completing induction training. Staff said they felt supported by the registered and deputy manager. There said they worked more like a family and were able to discuss any issues with the manager, who was approachable and listened to their views.

A system of recruitment checks were in place to ensure that the staff employed to support people had the skills and experience to carry out their role. Further details of how decisions were made to employ staff who may need to be monitored were not in place to ensure they did not pose a risk to people living at the service.

There were sufficient numbers of staff on duty throughout the day and night to make sure people were safe and received the care and support that they needed at all times. People said there was enough staff to take them out to do the things they wanted to.

Staff were caring and respected people’s privacy and dignity. They treated people with kindness, encouraged their independence and responded to their needs.

Before people decided to move into the service their support needs were assessed by the registered manager to make sure they would the service would be able to offer them the care that they needed. People were invited to spend time at the service before they actually moved in so that people would get to know each other and the staff who supported them.

Each person had a care plan in place and the service was in the process of introducing a new format of personalised care planning. The current care plans contained detailed information needed to make sure staff had guidance and information to care and support people in the way that suited them best. People’s likes and dislikes were recorded and how to the plans had been regularly reviewed. People were supported to maintain good health and received medical attention when they needed to. Appropriate referrals to health care professionals were made when required.

Medicines were stored securely and administered safely.

People were offered and received a balanced and healthy diet. They could choose what they wanted to eat and when they wanted to eat it. People said that they enjoyed the food and told us what their favourite things were. People looked healthy and if guidance was needed about their dietary needs they were seen by dieticians or their doctor as required. People were supported to maintain a healthy weight and encouraged to exercise to remain as healthy as possible.

People’s activities were listed and what they preferred to do but there were no clear goals as to what future aspirations they would like to work towards achieving. People’s rooms were personalised and furnished with their own things. The rooms reflected people’s personalities and individual tastes.

There was a new complaints procedure in place but this was not available in a format that was accessible to people who used the service. People did not have any complaints and staff told us that any concerns and issues were always dealt with by the registered manager, who was always available to address any issues. There had been no complaints during the last year.

The registered provider had not informed CQC of two notifiable incidents that occurred within the service. However, the service had contacted each person’s care manager at social services and, where required, appropriate support had been provided by other health care professionals to make sure the people were safe.

Some checks, such as the testing of the fire alarm system, had been carried out on the premises; however further checks, such as auditing the care plans, health and safety, and in house medicine audits, had not been recorded. The registered manager told us that the premises were checked on a daily basis and if any shortfalls were identified these were addressed. However, the checks in place had not identified the shortfalls found during the inspection, and there were there were no reports following any audits to detail any issues found and the actions that may need to be taken. Minor repairs had been completed in the service and re-decoration of some areas had also been carried out, but there was no maintenance plan in place to show ongoing plans to refurbish the service.

People and relatives had been sent surveys to comment on the quality of the service, and positive feedback about the service had been received. However, there was no system in place to gather comments from health care professionals and staff to enable them to be involved in the continuous improvement of the service.

There was a file containing personal information about each person using the service, which included guidelines on how to move people out of the home in the event of an emergency of if they should they need to go to hospital. The registered manager told us that they were in the process of writing a business continuity plan to include all such information. The registered and deputy manager covered an on call system so that staff had a manager available for guidance and support at all times.

Staff told us that the service was well led, and they felt supported and by the registered manager who took action to address any concerns or issues straightaway, to help ensure the service ran smoothly. They said they worked well as a team and there was a culture of openness as the registered manger worked with them on a daily basis.

Although records were stored securely and confidentially, not all records were available at the time of the inspection such as staff appraisals and the minutes of staff meetings.

The provider had recently had all of the policies and procedures updated in line with the Health and Social Care Act 2008 regulations and were in the process of implementing all of the changes required. They recognised there were some shortfalls in the service and were working towards addressing these issues.

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.

People who used the service told us that they were happy living at the home One person said “It’s nice here, I like it” Relatives we spoke to told us that they were happy with their relatives care. One relative told us, “My relative used to have lots of outbursts and became physically aggressive, but since they have been at the home, their behaviours have reduced and they are much happier. It’s a great home for them, it’s great to see them so happy and settled”.

We saw that people who used the service were encouraged to make decisions and choices on a daily basis. Staff we spoke to were able to demonstrate that they had built a good rapport with the people who used the service and knew them and their wants and needs, well.

We found that people chose what they wanted to eat at meal times each day and that they were included in the preparation of their own meals and we saw positive results from a recent survey which had been sent to peoples relatives.

We found that staff had the knowledge skills and qualifications appropriate to their job roles and that there were robust recruitment processes in place. In addition, the service was monitored regularly in order to maintain the quality of the service provided.

People who use services said that the staff treated them with respect, listened to them and supported them to raise any concerns they had about their care. People told us that the service responded to their health needs and that staff talked to them regularly about their care and any changes that may be needed.

People told us they received care from a small team of staff and were happy with the care received and had no concerns relating to the home.

All spoken with expressed a great deal of satisfaction from living within the service and did not raise any concerns about the quality of care. All said that if they were not happy they would speak to staff or the manager.

A relative spoken with was very complimentary of the quality of care provided. He commented that “I can’t fault them at all, staff are very good”. He also said “My son is very happy living there” and “I am kept fully informed”.

However, practice and administration of medicines potentially put people who used the service at risk due to the failure to follow guidance and policy.