This unannounced inspection took place on the 15 and 16 January 2018. Chiltern 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.

At the time of the inspection there were 44 people living in the home. Chiltern Grange Care Home can accommodate 75 people across three separate floors, each of which have separate adapted facilities. One of the floors specialises in providing care to people living with dementia.

The service had 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.

When we completed our previous inspection on 23 and 24 April 2017 we found concerns relating to end of life care documentation. At this time this topic area was included under the key question of “Is the service caring?” We reviewed and refined our assessment framework and published the new assessment framework in October 2017. Under the new framework this topic area is included under the key question of “Is the service responsive? Therefore, for this inspection, we have inspected this key question and also the previous key question of “Is the service caring?” to make sure all areas are inspected to validate the ratings.

During our previous inspection on 23 and 24 April 2017 we found a number of breaches of regulations. These included Regulations 9, 11, 12 and 17 of the Health and Social Care Act 2008 and Regulation 19 of the Care Quality Commission (Registration) Regulations 2009. Following the last inspection, we spoke with the provider and asked them to complete an action plan to show what they would do and by when to improve all the key questions to at least good.

During this inspection we found improvements had been made to all the areas that we previously reported as required improvement. During this inspection we found records were up to date, accurate and appropriate. Records related to risks had clearly identified the risk and the methods used to minimise risk. Standards of infection control were high with clear policies and procedures in place to minimise the spread of infection. The management of risks in relation to fire, health and safety and risks related to the provision of care were clearly recorded.

We observed and records demonstrated that improvements had been made to the administration of medicines. During this inspection we found medicines were administered in line with the prescribed times. Records were kept up to date and audits had proved effective in ensuring people received their medicines correctly.

Improvements had been made in the way staff were deployed. Through our observations and records of staff rotas we could see there were sufficient numbers of staff to ensure people’s needs were met.

Systems were in place to ensure the risk of employing unsuitable staff was minimised.

During our previous inspection in April 2017 we found the provider had failed to comply with the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DoLS). During this inspection we found this had improved and the provider was now compliant with the requirements of the Act. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems at the service supported this practice.

We observed food was presented in an attractive way to encourage people to eat and maintain good health. People’s dietary needs were identified and understood by staff who were involved in the preparation and delivery of food. People told us t

This unannounced inspection took place on the 23 and 24 April 2017. Chiltern Grange Care Home is a registered care home that provides residential and nursing care to young adults, older people and people living with dementia. The home is registered to accommodate 75 people. At the time of the inspection there were 42 people living in the home. The home has three floors including the ground floor with lifts and stairs to all floors.

During the previous inspection in May 2016 we found breaches of Regulation 12 and Regulation 17 of the Health and Social Care Act 2008(Regulated Activities) Regulations 2014.This was because people were not protected against the risks associated with the proper and safe management of medicines. Care related documents were not always up to date or accurately reflected people’s needs. During this inspection we found continued breaches of these regulations and further areas of concern.

The home had been without a registered manager since June 2015. Although there had been a number of managers in place since this time, none had completed the registration process with the Care Quality Commission (CQC). At the time of the inspection a new manager was in post. They had started employment at the home on the 6 March 2017. They intended to register with CQC. 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 had concerns about the safety of the service, For example, people living with dementia did not always have supervision from staff.

Records related to care were not always up to date and accurate. Care plans did not clearly document changes in people’s needs. Risk assessments were not always completed correctly. This placed people at risk of receiving inappropriate and unsafe care.

Staff recruitment was undertaken in such a way as to minimise the risk of employing staff who might be unsuitable to work with the people living in the home. Checks were made on the suitability and previous conduct of applicants.

Training, supervision and appraisals were provided to staff to encourage good practice and equip them with the skills and knowledge necessary to carry out their roles. Staff told us they felt supported in their role and they had received sufficient training to carry out their role competently.

The home was clean and odour free. The environment was comfortable and well maintained. Health and safety checks were completed to ensure the safety of the building and the wellbeing of the people living in the home, staff and visitors.

Staff did not understand the Mental Capacity Act 2005 (MCA) and how it applied to their role. Records did not demonstrate where decisions were being made on behalf of people who lacked the mental capacity to make their own decisions. The best interest process had not been followed. Mental capacity assessments were not always decision specific and these had not always been reviewed. People were not supported to have maximum choice and control of their lives. The policies and systems in the service did not support this practice. However, staff did support people in the least restrictive way possible. Where restrictions were in place to protect people’s welfare, appropriate applications had been made to the local authority for authorisation.

Staff were caring, considerate and treated people with respect. We observed positive interactions between staff and people. People spoke optimistically about their relationships with staff.

We had concerns that personal information was not always stored in a secure way, which preserved the confidentiality of information. Records related to Do Not Attempt Resuscitation forms were not always completed correctly or accurately. People’s preferences

This unannounced inspection took place on 23 and 24 May 2016. During our last inspection in October 2015 we found nine breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and the CQC (Registration) Regulations 2009. During this inspection we found improvements had been made in all areas apart from the administration of medicines and care plans which required further improvements.

A requirement of registration is the necessity of a registered manager to be in place in the home. There was no registered manager in place, however a new manager had commenced employment in the home two weeks prior to the inspection. It was their intention to register with the commission. 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 previously inspected the service in October 2015 We found that people did not consistently receive safe care and treatment, in relation to medicines, record keeping, staff training, support for staff and notifying the commission of events in the home. The provider sent us an action plan, to tell us what action they were taking to improve the service.

Over all people spoke positively about the care and support they received in the home. Their only criticism was in relation to agency staff. This was because they felt the agency staff did not know what their individual needs were. The home had relied heavily on agency staff due to a high staff vacancy rate. This situation had improved recently due to a new intake of permanent staff.

The home has also been through many changes of management over the last couple of years, however a new manager is now in place and people and staff appear to have confidence in their ability to improve the service on offer.

Staff knew how to protect people against the risk of abuse, and the whistleblowing policy was up to date and accessible to staff.

We found a number of concerns related to the administration of medicines to people living on the ground floor. There were incomplete records of stock balances, and for one person with epilepsy there was no seizure chart. Another person’s pain chart had not been reviewed until the day of the inspection. One person’s medicine had not been signed as given and stocks of medicines did not tally with the expected recorded amount. Records on the other two floors were accurate and up to date.

The provider had a tool to assess the number of staff required on each floor to meet people’s needs. People and one staff member told us there were insufficient staff members on the ground floor. During our inspection we found there appeared to be enough staff available to meet people's needs. We have made a recommendation about reviewing the staff numbers on the ground floor.

Appropriate checks were made in relation to the recruitment of staff, to ensure where possible only candidates safe to work with people were employed.

Improvements had been made to the assessments of risk to people’s health and safety since the last inspection. This included Legionella, fire, control of substances hazardous to health (COSHH).

During our last inspection we had concerns regarding the lack of training and support for staff. This had improved. We found staff were encouraged to attend appropriate training to enhance their skills and knowledge. Further work was underway to ensure all staff received appropriate training and support.

Mental capacity assessments were appropriately completed and where appropriate applications had been made to the local authority for Deprivation of Liberty Safeguards (DoLS).

During our last inspection we had concerns about the lack of support for people with their eating and drinking. During this inspection we f

This inspection was a follow up to our last inspection in April 2014. This inspection was carried out by a pharmacist inspector to assess what the provider had done in response to the action we had told them to take with regards to the safe management of medicines.

This is a summary of what we found-

Is the service safe?

We found the service was not safe because people were not protected against the risks associated with medicines. We found that there had been some improvements made to the way medicines were handled and managed in the service since our previous inspection but there were still actions that the provider needed to take to ensure that people received their medicines safely.

You can see our judgements on the front page of this report.

This unannounced inspection took place on the 26 and 27 October 2015. The home is registered to provide nursing or personal care for up to 75 young and older people including people who live with dementia. At the time of the inspection there were 58 people living in the home. The home is required to have a registered manager in place. 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. Previously the home had been inspected in July 2015, this was a focussed inspection to see if the home had made improvements in the areas of Safe, Effective and Responsive. It was rated as good in these areas.

At the time of the inspection there was a new manager who had commenced employment with the provider four weeks prior to the inspection. They intended to become the registered manager.

During this inspection we found that infection control audits had been completed but there were no action plans in place to address the points of concern found in the audit. Legionella testing was not up to date and actions required to ensure the safety of the home in relation to legionella had not been completed.

The home was clean and well maintained. People had their own rooms and en-suite facilities. They were able to personalise their rooms with their own belongings.

People told us they felt safe living in the home, however, the manager was not aware of how to respond to allegations of abuse in such a way as to protect evidence. The home’s whistleblowing policy did not ensure staff had clear information of how to report concerns outside of the home and where possible, their identity would be protected. The safeguarding policy made no reference to the multi-agency agreement and the local authorities expectations of how safeguarding concerns should be addressed in the home.

Some aspects of the administration of medicines was not safe for example, signing the medication administration record (MAR) prior to administering medicine to people. We also observed prescribed fluid thickeners were being shared between people, rather than each person receiving their own. This is not in line with the guidance from the Nursing and Midwifery Council (NMC).

Training and supervision had not always been carried out for all staff. We noted that according to the records, three staff members who were carrying out the administration of medicines had not received training to administer medicines to people and their competency had not been assessed. Regular supervision of staff did not always take place this meant the provider could not demonstrate they had monitored and supported staff in relation to the duties they were employed to perform

Checks were undertaken to ensure new employees were safe to work with people. Where agency staff were used, the agency provided the home with a profile showing that appropriate checks had been completed and their knowledge regarding policies and procedures was up to date.

People told us there were not enough staff; however on the day of the inspection we saw there were sufficient numbers of staff to provide the care and support necessary. A significant percentage of the staff in the home were agency staff, as there were approximately nine staff vacancies at the time of the inspection.

The requirements of the Mental Capacity Act 2005 were understood by some staff, and where required the home had made applications regarding the deprivation of liberty safeguards. We could see no documentation to show how staff acted in people’s best interest when it came to making serious decisions that would affect people’s lives.

Care records were not always completed accurately or updated appropriately. This meant monitoring of people’s health and care needs was not effective.

We saw some positive interactions and strong relationships between some staff and people who lived in the home. However, we also saw poor communication between staff and people, and where two people who needed extra support with their food did not receive this from staff.

Records showed complaints were not always followed through in line with the home’s procedure and the new regulations.

People participated in activities such as puzzles, board games, arts and crafts, sing-along and painting but plans were in place to improve the quality and the quantity of activities.

The frequent change in management over the last 14 months meant there had been no consistency in the management approach. There had also been a large turnover of care and nursing staff. The Care Quality Commission (CQC) had not always been informed about changes in the home that legally they are required to do.

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.