This unannounced inspection took place on 24, 25 October and 1 November 2018. Grosvenor Gardens 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. This was the first inspection of the service since a change of ownership in October 2017.

The home is required to have a registered manager. 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. At the time of this inspection, the home did not have a registered manager.

The home is registered to accommodate up to 137 people and 86 people were living there at the time of this inspection. Accommodation was provided in four, single storey Villas. Orchid Villa accommodated people living with dementia who required nursing care; Lavender Villa accommodated people with enduring mental health needs; and Rose Villa accommodated people with general nursing needs. At the time of the inspection, Bluebell Villa was being used as staff accommodation.

The service was being managed by the provider’s Operations Director. They told us they had overseen the transfer of the service from Bupa to Cedar Care during the latter months of 2017 and early 2018. A manager had then been appointed but had now left the home.

During the inspection we identified a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Staffing.

The Operations Director told us that a programme of basic training had been provided for new staff, but due to the considerable staff turnover over the last year, implementation of more in-depth training to give staff a better understanding of the support people needed and their responsibilities in terms of health and safety, had been delayed. Staff supervision records showed an inconsistent provision, with some staff having no individual support meetings.

During the inspection we observed that there were enough staff to meet people’s needs, however some of the staff and visitors we spoke with still considered that there were not always enough staff on duty. We recommend that the provider keeps this under continuous review.

People told us they enjoyed their meals and had enough to eat and drink. However, the meal served during our inspection was of poor quality and we saw a lack of choice and variety for people who required their meal to be of a soft texture.

Over the last twelve months, the nurses had been changing people’s care documentation from the previous provider’s system to the Cedar Care format. We saw that in one of the Villas this had been completed successfully, but this was not consistent across the service which meant that accurate and up to date information was not always available.

People we spoke with believed the home was safe. Maintenance records showed that regular checks of services and equipment were carried out by the home’s maintenance person and testing, servicing and maintenance of utilities and equipment was carried out as required by external contractors.

A programme of refurbishment was almost completed to provide people with a light, bright and pleasant environment. All parts of the premises looked clean and the kitchen had a five star food hygiene rating.

People’s medication was stored and handled safely, with minor issues identified for improvement.

A log of accidents and incidents was maintained and the records showed that appropriate action had been taken when accidents occurred.

The service complied with the requirements of the Mental Capacity Act 2005 and appropriate Deprivation of Liberty Safeguard applications had been m