The inspection was unannounced and took place on 17, 20, 21 and 23 August 2018.

The service provides care for older people with physical disabilities and dementia who require residential or nursing care. There were 43 people living at the home at the time of our inspection. The home can accommodate up to 50 people and a registered manager is a requirement of registration with CQC.

Cheshire 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. The care home comprised of three floors with a passenger lift in between each floor. People living on the ground had both residential and nursing needs. People living on the first floor of the home were either living with dementia on a specialist dementia unit or were living adjacent to the dementia unit on a residential care needs unit. There was a training room and staff room on the third floor. The home had well kempt gardens and a veranda for people to sit and look out over the gardens.

The home was being run by an acting manager at the time of our inspection and there was no registered manager in post. The previous registered manager had deregistered with CQC on 26 July 2018. The acting manager had informed us of this change on 17.7.18. A condition of registration with CQC is that the home is run by 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.

The acting manager had started in the home in June 2018 and was well respected by staff and people who lived at the home. We could evidence Improvements were in the process of being implemented by the acting manager however, the quality assurance systems in place at the time of our inspection had not identified all of the concerns we found. We identified breaches of Regulations 12 Safe Care and Treatment, 13 Safeguarding people from abuse, 17 Governance and 18 Staffing of the Health and Social Care Act Regulations 2014.

You can see what action we told the provider to take at the back of the full version of the report.

We found one risk assessment which had not been put in place for use of bedrails and another risk assessment which had not been reviewed appropriately. Another person who was using oxygen at times had no risk assessment for their oxygen equipment and the risk around its use.

Medicines were being managed safely with medication errors being logged and learning being taken the incidents.

Safeguarding systems were not robust enough as we found one person who raised an allegation of being handled "roughly" had faint unexplained bruise marks which had not been body mapped or reported to the appropriate authorities. Staff we spoke with could tell us about the different types of abuse and how to report a concern. Staff were aware of whistleblowing.

Not all safeguarding concerns which had been sent to the Safeguarding Authority had been notified to the CQC which is a legal requirement.

Assessment of people's care needs were not always detailed enough to provide person centred care. Likes and preferences were seen in the care plans.

We raised concerns regarding the deployment of staff/staffing numbers during our inspection. The dependency tool used was not capturing the amount of time individual people needed to eat, drink and for other daily tasks. We found some people were not receiving interaction/stimulation for long periods.

Quality assurance systems and checks in place had not addressed all the issues we found on this inspection such as staffing, informal complaints not being processed, some risk assessments being

The people using the service who were able to tell us said that they were happy living in the home. Comments such as "this place is superb""fabulous place,fabulous staff" " it is a great place to live." People spoken with said "the staff are wonderful" "staff are superb" "feel very supported by staff".

Staff were seen to be considerate and polite and there was a pleasant, relaxed and friendly atmosphere throughout the day as people talked freely with each other visitors and staff. There was a lot of pleasant banter between residents, staff and visitors.

Comments from staff included "It is a lovely place to work;" I really enjoy my job" and "we are a family."

We carried out an inspection over a period of three days, 6, 9 and 29 July 2015. The first day of the inspection was unannounced and the further two visits took place to gather additional information.

Cheshire Grange is a care home which provides nursing and/or personal care for up to 50 people including those individuals living with a dementia including Alzheimer's disease. The home is located in the village of Lymm near Warrington. The home was purpose built in 2012. There were 42 people living at the home on the day of our visit.

The home had a manager in post who was registered with CQC. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider. At the time of our visit the home was being run by the deputy manager with the support of the registered manager who was on secondment within the company.

Cheshire Grange was last inspected on 23 April 2013 when it was found to be meeting all the regulatory requirements which were inspected at that time.

We found the ethos and culture of Cheshire Grange was positive and caring and staff were passionate about working at the home and treating each person as an individual which showed us that the home was outstanding. During our inspection we saw that the relationships between staff and people living at the home were warm and caring, respectful, dignified and with plenty of smiles and laughter and hugs. Everyone in the service looked relaxed and comfortable with all of the staff.

We spoke to staff who were committed to providing individual care to the people who live at the home and put them at the heart of everything. We saw that the home followed national guidance to ensure people received care that was based upon best practice. People were well supported by experienced well trained staff. All staff spoken with said they had received good training to help them to understand and care for people living at Cheshire Grange.

People we spoke with and their relatives felt that they and their loved ones were looked after by staff who were caring and had training so that they knew what they were doing. One relative told us,” My relative has been here a few months, all the staff are looking after them and I am very happy with the care.” One person said “ My room is very personalised and they look after me very well. ”

We asked people about the food that was on offer at Cheshire Grange and were told “The food is very good,” “You can have a full breakfast, a three course lunch supper and drinks at any time,” and “Good choice of good food.” The dining experience was positive with tables set with table cloths, napkins and salt and pepper on the tables.

Care records showed that plans of care were person centred and reflected the needs of the individual past histories and experience so that staff were aware of who the person is not just the care they required. This ensured that people were supported in the way they wanted to be.

Activities on offer were varied and reflected the hobbies and interests of people prior to them living at Cheshire Grange where possible. People were supported to be involved in activities that meant something to them and risk assessments were in place to enable them to do this. The provider had effective procedures for ensuring that any concerns about peoples safety were appropriately reported and were constantly striving for improvement.

People, relatives and staff felt that the home was very well managed. We found that all the staff team were well led and highly motivated to provide quality individual person centred care and all spoken with said they felt proud to work at Cheshire Grange.

We saw that the home strived to constantly improve through good practice. We saw that learning was based on the experiences of people at the home living with dementia and this had fed into staff training and development. This enabled all grades of staff at the home to have some insight in to an individual person’s dementia journey.

We found that medicines were properly managed so that people were ensured they were given the right medications at the right time they were prescribed. This was supported by the use of an electronic medication management system.

We saw records of how complaints were managed  and we saw that they had all been dealt with promptly and an explanation of how they had been resolved retained so that occurrences were minimised.