This inspection took place on 11 September 2018 and was unannounced.

We inspected the service to follow up on the breaches and to carry out a comprehensive inspection.

At the last inspection in July 2017 the service was not meeting all of the legal requirements with regard to regulations 9, person-centred care and regulation 17, governance.

At this inspection we found improvements had been made but further improvements were required with regard to aspects of people’s care. We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This related to safe care and treatment, regulation 12, staffing levels, regulation18 and person centred-care, regulation 9.

Bedewell Grange 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.

Bedewell Grange accommodates a maximum of 50 older people, including people who live with dementia or a dementia related condition, in one adapted building. At the time of inspection 44 people were using the service.

A new manager was in place who was introducing some changes and improvements to the home. They had started work in September 2018 and were in the process of applying for registration with the Care Quality Commission.

People said they felt safe and they could speak to staff as they were approachable. However, we had concerns staffing levels were not sufficient or staff appropriately deployed to ensure people received safe and person-centred care.

People were not always supported to have maximum choice and control of their lives with staff supporting them in the least restrictive way possible, the policies and systems in the service did not always support this practice.

Records reflected the care provided by staff and they were regularly evaluated but we considered further improvements were required to ensure people received person-centred care when they were unable to tell staff how they wanted their care to be provided.

People were supported with eating and drinking as needed and systems were in place to ensure they received a varied diet.

Risk assessments were in place and they identified current risks to the person. Staff knew the people they were supporting well.

People were protected as staff had received training about safeguarding and knew how to respond to any allegation of abuse. When new staff were appointed, thorough vetting checks were carried out to make sure they were suitable to work with people who needed care and support.

Appropriate training was provided and staff were supervised and supported. Staff had an understanding of the Mental Capacity Act 2005 and best interest decision making, when people were unable to make decisions themselves.

Staff followed advice given by professionals to make sure people received the care they needed. Systems were in place for people to receive their medicines in a safe way. Communication was effective to ensure staff and relatives were kept up-to-date about any changes in people’s care and support needs and the running of the service.

A complaints procedure was available. Staff and relatives said the management team were approachable. People had the opportunity to give their views about the service. There was consultation with people and family members and their views were used to improve the service. People had access to an advocate if required.

The home was clean and well-maintained for the comfort of people who used the service. The home was designed to promote the orientation and independence of people who lived with dementia.

Bedewell Grange is registered to provide accommodation and personal care for up to 52 people, including some people who were living with dementia. At the time of our inspection there were 45 people living at Bedewell Grange.

This inspection took place on 4 July 2017 and was unannounced. This meant the provider did not know we would be visiting. A second day of the inspection took place on 6 July 2017 and was announced.

The home had a registered manager in place. 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 legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the last inspection on 10 and 11 March 2015, the service was rated Good. At this inspection we have made recommendations about the deployment of staff and the review of the Mental Capacity Act 2005 Code of Practice regarding the role of Lasting Power of attorney (LPA). During this inspection we identified two breaches of regulation. Care records did not always reflect the appropriate treatment and care needs of people who used the service and the provider did not have effective quality assurance processes to monitor the quality and safety of the service provided and to ensure that people received appropriate care and support.

Staff had completed training to ensure they were able to recognise the types of abuse and take appropriate action. The registered manager had dealt with safeguarding concerns immediately.

Where risks were identified they were assessed and managed to minimise the risk to people who used the service and others.

Medicines records we viewed were complete and up to date. This included records for the receipt, return and administration of medicines.

Staff had completed mandatory training required to perform their role. We noted all training was up to date as were supervisions and appraisals.

The provider carried out monthly health and safety checks including fire safety to ensure people lived in in a safe environment. A business continuity plan was in place to ensure people would continue to receive care following an emergency.

A robust recruitment process was in place ensuring staff had the appropriate skills, experience and knowledge to care and support people.

People were not always supported to have maximum choice and control of their lives. Staff supported people in the least restrictive way possible and the policies and systems in the service support this practice.

Kitchen staff had an understanding of people’s dietary needs. People were promoted and supported in maintaining a healthy diet.

We observed staff were kind, caring and compassionate towards the people they supported. Relatives we spoke with told us staff were always respectful.

People and relatives knew how to make a complaint. Relatives told us both the registered manager and deputy manager were approachable.

Whilst care plans were comprehensive and contained detailed information this was not consistent and people’s needs were not always accurately reflected through relevant care plans.

The service had developed good working relationships with external health care professionals visiting the service. We saw evidence in care plans of cooperation between care staff and healthcare professionals including, occupational therapists, nurses and GPs.

The service was proactive in seeking feedback from people, relatives and staff in order to monitor and improve standards.

The registered manager ensured statutory notifications had been completed and sent to the CQC in accordance with legal requirements.

The service had a range of activities. People were supported to maintain links to their local community.

The provider had recognised some of the areas for improvement we had identified during our inspection however they had not

On the day of our inspection visit we found 45 people out of 52 living at Bedewell Grange.

Comments from relatives included "I am happy with Bedewell. The staff are great with my x. They are always letting me know what is going on". "The manager is at hand if I have any questions in relation to my x".

Care plans were written in a clear and easy to understand way and people's personal preferences were clearly recorded. There were sufficient staff on duty to support people with their care needs.

We looked at how the service recruited staff by checking six staff files. These showed that the appropriate checks and procedures were being followed.

We found people who used the service understood the care and treatment choices available to them. People's needs were assessed, and the planning and delivery of care and treatment met their needs and protected their rights.

The provider had an effective system to regularly assess and monitor the quality of service that people received. They also had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who used the service.

We found people who use the service, staff and visitors were protected against the risks of unsafe or unsuitable premises.

People we spoke with told us they were happy with the care they received and liked living at the service. A visitor we spoke with confirmed they were satisfied with the care their relative received and had no concerns. People said they liked how the manager knows all of their names, and the care staff always made sure any concerns were passed to the senior staff members if they could not resolve it easily themselves. No one we spoke with had needed to use the complaint process.

People who use the service were asked how they feel about living at the home and the staff who look after them. These comments include “I love it here", “they look after me well” and “they are very caring and work hard".

Relatives were positive about the home and said they were “very happy with the care” and staff were “approachable” and “friendly”.

This inspection took place on the 10 and 11 March 2015 and was an unannounced inspection. The last inspection took place on 23 April 2013. At that time the service was meeting the regulations we inspected.

Bedewell Grange is a 52 bed care home that is registered to provide accommodation for persons who require personal care. Nursing care is not provided. At the time of inspection there were 41 people resident. The home has a registered manager who was absent due to ill health at the time of this inspection. A covering manager from another Barchester home nearby was managing 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. The home was split over two floors, with the upstairs for people living with a more advanced dementia or higher support needs.

The home was warm and clean. There was re-decoration going on in the home in the bedrooms and communal areas. There were sufficient staff to meet people’s needs, five carers on duty, with two seniors, a chef and assistant, three domestics, the manager and two deputies (one being supernumerary) and an administrator.

The covering manager had taken the learning from recent safeguarding incidents and translated that into practice. For example, there was evidence of improved recording and care planning, as well as increased referral to, and support from external professionals. These all contributed towards better outcomes for people with complex physical and mental health needs.

Staff supervision and training plans were not up to date, but the covering manager had taken steps to source additional external training and re-started supervisions and this was being addressed.

Medicines were managed safely in the home. Where sedation was used it was used appropriately and staff knew how to identify and respond to any concerns about medication. Staff were trained and supported to manage medicines safely. Additional training on supporting people with Parkinson’s disease had been sourced and the deputy manager was to roll this out across the staff team.

People told us the staff were effective and that they had their needs attended to promptly. People told us they or their families were involved in their care planning and that they felt staff knew them well. Where people’s needs were complex external medical and social care professionals were referred to promptly and their advice integrated into care plans.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS). DoLS are part of the Mental Capacity Act 2005. These safeguards aim to make sure people are looked after in a way that does not inappropriately restrict their freedom. There were a number of people subject to DoLS and these had been managed well by the service with new referrals being made appropriately. The service had a system in place to ensure that renewals are requested promptly.

During the inspection we noted positive interactions between people and staff, these were sympathetic and dignified. People’s privacy and choices were respected, knocking on doors before entering. One person commented “They are all lovely to us in here” and another “I couldn’t fault them. It’s like a hotel”.

There was evidence of planned activities, but some staff and people did say that they would like to have more time doing activities and leisure pursuits in the home. The covering manager advised the new activities co-ordinator was developing this area further.

One person who told us they had complained in the past about delays to be assisted to use the bathroom told us that things had improved, and it was observed that call bells were answered promptly.

The covering manager had taken action to identify areas for the home to improve, had recruited new staff and was taking steps to ensure that record keeping, supervision and training were updated. The covering manager had also taken time to get to meet many of the residents and their families and had responded to their concerns. The staff team said they felt supported and encouraged to improve by the covering manager.