The inspection took place on 8 and 12 June 2017 and was unannounced.

Anisha Grange is a nursing home that is registered to provide accommodation, nursing and personal care for up to 74 older people, some who may have needs associated with dementia. Care was provided in three units over three floors. Valentine, the nursing unit, was on the ground floor, people with dementia mainly lived in the Primrose unit on the first floor, whilst people who did not have nursing or dementia needs predominantly lived in the Autumn Way unit on the second floor. At the time of our visit there were 67 people living in the service.

A registered manager was not in post at 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. We were told that the manager was applying to the Care Quality Commission to become the registered manager.

When we last visited the service we found that there were not enough staff to meet people’s needs and minimise risk, in particular where people had the most complex needs. Morale was low amongst staff and the manager did not have sufficient oversight of the care people received. Whilst there were action plans in place to resolve the concerns we had found they were not leading to improvements.

At this inspection we found the service people received had improved dramatically and the provider had addressed our concerns openly and pro-actively. Whilst there had been an unsettled period following our last inspection the service was now running more smoothly and feedback from people, families and staff was overwhelmingly positive.

People were safe at the service. The checks on people’s health and wellbeing had been enhanced. Staff and managers were more aware of where there were risks in the service which needed to be monitored or acted upon. Staff knew what to do if they were concerned about people’s safety. There were enough staff on duty who were organised efficiently and worked well as a team. Staff were safely recruited, and the use of agency staff was proportionate. Medicines were administered safely.

There was a focus on developing staff skills through more effective and meaningful training. Staff were well supervised and supported. The service was meeting its responsibilities under the Mental Capacity Act (MCA) 2005. People were supported to make their own choices and where there were restrictions on their liberty, these were minimised and in their best interests. Improvements had been made in the dining experience and these were on-going. People who were at risk of malnutrition or dehydration were well monitored and supported. Staff worked well with outside professionals to meet people’s needs.

Staff had an enthusiasm for the people they supported and this meant people felt valued and cared for. There was a focus on the person rather than the task being carried out. People were enabled to make choices about the support they received. They were treated with respect and dignity.

People were supported to take part in varied activities or pastimes of their choice by enthusiastic staff. Support was more holistic and tailored around people’s individual needs. Care plans provided staff with personalised guidance about people’s needs which enable them to understand what support people needed. Families and significant people were welcomed at the service. Their feedback was encouraged and used to make a difference. People felt able to raise concerns and the manager and staff learnt from their complaints and feedback.

The manager had helped transform the culture at the service. There was an openness and transparency about what improvements were needed at the service, and a commitment to excellence. The staff team were no

The inspection took place on 11 and 12 May 2016 and was unannounced.

Anisha Grange is a nursing home that is registered to provide accommodation, nursing and personal care for up to 74 older people, some who may have needs associated with dementia. Care was provided in three units over three floors. Valentine, the nursing unit, was on the ground floor, people with dementia mainly lived in the Primrose unit on the first floor, whilst people who did not have nursing or dementia needs predominantly lived in the Autumn Way unit on the second floor. At the time of our visit there were 74 people living in the service.

A registered manager was in post at 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.

We found a number of 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 the report.

Action plans were already in place to positively address many of the areas of concerns which we had picked up during our inspection. However, this had not yet resulted in improvements in the quality and safety of the service people received.

People were not always safe. There were not enough staff to meet people’s needs and minimise risk. Medication was managed and stored safely. However, medicines on the Valentine unit were administered by the member of staff who was also responsible for running the unit, which increased the risks of errors due to frequent interruptions and resulted in delays in people receiving their medicines. Staff were safely recruited and protected people from the risk of abuse.

There was an extensive menu on offer throughout the day and kitchen staff met with people to consult with them about the choices available. However, people did not always have a positive mealtime experience. There were not effective systems in place to ensure people who could not communicate verbally or who needed more support had ready access to drinks and snacks outside mealtimes. Measures to monitor people who were at risk of dehydration and malnutrition were not effective.

Staff did not always feel listened to and supported. Whist staff received a wide range of training; there were limited systems in place for the manager to monitor the levels of skill and knowledge amongst the staff team.

Whilst some staff were caring, other staff were often focused on tasks rather than the person they were supporting and did not always speak to people kindly.

Care plans and risk assessments were in place to provide guidance for staff about how best to meet people’s needs and preferences. People were supported to access relevant health and social care professionals. Staff arranged a wide variety of activities and events designed to enhance people’ quality of life. Lack of staffing meant support was not always person centred and some people were not able to attend the activities on offer.

The service was meeting the requirements of The Mental Capacity Act 2005 (MCA). Assessments of capacity had been undertaken and applications for Deprivation of Liberty Safeguards (DoLS) had been made to the relevant local authority. Whilst some staff asked for consent before carrying out care this was not consistent across the service. Improved training had been set up to increase knowledge and understanding of the MCA.

The manager was approachable and committed, however they did not always communicate with care staff and resolve their concerns effectively. There was insufficient supervision and a lack of oversight of the clinical care people received. People knew who to complain to and the manager responded to people’s concerns in a timely manne

During our inspection we spoke with 14 people who used the service and three visiting relatives. We also spoke with the Hospitality Manager and Acting Regional Manager and 10 staff.

We looked at the care records for six people. We also looked at how people were involved in their care and in developing the service, how safe they were, support and supervision systems for staff and quality assurance checks.

We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is a summary of what we found;

Is the service safe?

Staff had received a range of training to protect people from harm. Safeguarding of vulnerable adults from abuse (SOVA), Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS) training were completed every year. Staff we spoke with told us that they were aware of the action they would take if they suspected abuse was or had taken place. They were also aware of what it meant to deprive someone of their liberty and why this was sometimes necessary. This assured people who used the service that staff had the knowledge to know how to protect them from harm.

We found that the service had suitable arrangements in place to gain people’s consent and assess their mental capacity to make decisions before acting on their behalf.

The policy, procedures and quality monitoring of the service included health and safety and reviews of care planning and delivery. This system was comprehensive and ensured people lived in a safe environment with safe care.

Is the service effective?

People's assessments showed that their care, support and treatment was planned and delivered in a way that ensured that their needs were being met. Individualised care meant that people were fully involved, where possible, in choices and decisions about their lives. This made their care more effective as it enhanced their wellbeing and independence. One person said, “The carers are really good and the food is alright."

Is the service caring?

We saw good interaction between staff and people who used the service. Staff spoke to people respectfully; they were caring and courteous in their manner. People told us that the staff were very kind and gentle. One relative said, “The staff are very caring here, very caring indeed.”

Staff had a good knowledge of people’s likes and dislikes. People told us that the staff treated them respectfully. One person said, “They [the staff] have a heart of gold.” People’s preferences and diverse needs had been recorded in their care files and care and support had been provided in accordance with their wishes. This showed that people were cared for by kind and caring staff.

Is the service responsive?

The service offered a range of activities and places of interest for people to go within the service. Themed areas such as a ‘shed’, library and café had been developed from listening to the views of people who used the service and their relatives. One person said, “I can choose to do something if I want, there’s always something going on.”

Reviews of people’s care and health records showed that the service made sure that people received their care in a joined up way. People were responded to on an individual basis and staff knew people’s needs well.

We saw from the records viewed that the service worked well with other agencies. A range of professionals from the community were involved in people’s care. This showed that people’s specialist health care needs were considered and that the service was responsive to people’s changing needs.

Is the service well-led?

A comprehensive quality monitoring process and improvement plan was in place. Regular care reviews and discussions about nursing, care and social needs with people who used the service and their families took place. This ensured that people’s changing needs and preferences were always taken into account. A survey had been sent to relatives to enable the service to capture peoples’ views and experiences.

Staff training and supervision was provided for all staff. They told us they felt supported in their role.

The service was well-led as it was continually improving in its care provision and in the environment to make Anisha Grange a good place to live and work.

The people we spoke to were happy living at Anisha Grange. They spoke positively about the staff team and the care provided. Comments included: "The care here is very good, you would go a long way to beat this home." and "The staff here have a nice manner and they have the time to care, it's really very good."

We found that the care management at the home was good, that staff knew the people living at the home well and that they were aware of people's rights and the need to seek consent from people.

We look at the management of medication in the home and found that it was in good order and that the management team monitored the systems in place, to ensure standards were maintained.

We looked at the staffing in the home and found that the provider and manager had systems in place to ensure that they provided the right levels of nursing, care and ancillary staff to meet the needs of the people in the home.

We found the the provider had a complaints management system in place and although complaints were minimal, where they had occured the management team at the home had dealt with them appropriately and objectively.

People using the service were happy living at Anisha Grange. They described the carer staff as 'caring' and 'kind'. People said they felt safe at the home and one relative told us that ''the staff team in the home made their relative's quality of life good'.