This inspection visit took place unannounced on 23 January 2019.

Norton Grange Nursing and Residential Care Home is a two-storey residential home which provides care to older people including people who are living with dementia. Norton Grange is registered to provide care for 29 people. At the time of our inspection visit there were 27 people living at the home. Care and support was provided across both floors and each floor had its own communal lounge and dining area. All rooms were en-suite and people had shared use of communal lounges, dining areas and bathroom facilities.

People in care homes receive accommodation and nursing and/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.

There was a registered manager in post. 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 our last inspection we rated the service Requires Improvement overall, and in each key area, except for caring that was rated good. We found people’s choices and decisions about their care were not made in line with the Mental Capacity Act and some people had unnecessary restrictions placed on their freedom. We found the providers audit systems and processes were not thorough so improvements were not always identified and/or actions taken. This meant there was a breach of the Health and Social Care Regulations for safe care and treatment and good governance. The provider sent us an action plan telling us how they would improve in these areas. We completed this inspection visit to check improvements had been made.

At this inspection visit we found improvements had been made and the provider was not in breach of the regulations. Further improvements and time to embed processes and systems of audits was still needed for the registered manager and provider to be confident actions resulted in the quality of service being improved. A range of current audits and checks helped ensure people received safe care that was delivered in a safe environment.

People and relatives were complimentary and satisfied with the quality of care provided at the home. People felt safe living with other people in the home and they were supported by a consistent, kind and caring staff team.

Staff were available at the times people needed and there were enough staff to respond to people’s needs and requests for assistance. Staff were trained but further training was planned to ensure people's care and support needs were met by staff who knew how to support them safely and effectively. Staff understood their responsibility to safeguard people from harm and to report any concerns they had to the management team. Staff were confident actions would be taken.

People's changing needs were responded to by staff and other healthcare providers were contacted when needed. People were treated with respect by staff who addressed them by their preferred names and who supported them in line with their personal preferences and wishes.

No one at the time of our visit received end of life care. The registered manager said care was given so if people wanted, ‘this was a home for life’. Anticipatory and pain relief medicines were arranged so if people’s condition quickly deteriorated, their care could remain as pain free and dignified as possible.

The registered manager worked in partnership with other healthcare professionals to ensure people received effective care that was responsive to their needs. The registered manager had built new relationships with support networks, other healthcare professionals, the local authority, commissioners of services and the local community. This hel

This inspection took place on 22 November 2017 and was unannounced.

Norton 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.

Norton Grange accommodates 27 people in one adapted building. The home has two floors. It provides nursing care to older people who live with dementia. On the day of our visit 22 people lived at the home and one was in hospital.

The registered manager recently left the service without working her notice of resignation. 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 last inspected Norton Grange in November 2016 and gave the home an overall rating of ‘requires improvement’. There were no breaches of the regulations. During this inspection visit we found further improvements were required and two breaches of the regulations. This is the third consecutive time the service has been rated as requires improvement.

The acting manager and acting assistant manager were being supported by the provider’s operational director to address issues that had recently been identified at the home, and to increase their knowledge and gain confidence in their roles.

At this inspection one person who lived at the home had not been allowed to leave the premises without an escort. This was, in the opinion of the manager, in the best interest for their safety. However the person did not want escorting and had the capacity to make this decision. Some of the authorised Deprivation of Liberty Safeguards had expired, and new applications had not been submitted. This meant the provider was not meeting the requirements of the Mental Capacity Act.

Since our last inspection visit there has been a high turnover of staff at the home. This has meant staff from an agency have had to cover the vacant positions and led to a reduction in the continuity of care experienced by people. The use of agency staff was now decreasing and there were enough staff on duty to meet people’s needs.

Medicines were mostly managed and given to people safely, however on the day of our visit we found one person had not been given their medicine in line with their care plan.

Risks to people’s health and well-being had mostly been identified. However there were times when the changes in the risks to people had not been updated or written in records to support staff in their knowledge.

The assistant manager and staff understood their responsibilities to protect and safeguard people from abuse. Recruitment practice supported the recruitment of people who were safe to work with people with complex health and social care needs.

Staff had received sufficient training to meet people’s needs. Some of the training to refresh staff skills and knowledge had not been provided within the timeframe expected by the provider.

People were provided with a choice of food at breakfast and tea time, but did not think they always had a choice at lunchtime. Most people enjoyed the meals provided. People with specific dietary needs were supported with these.

People’s health needs were supported by nursing staff who worked at the home and through timely referral to other healthcare professionals.

Staff were kind and caring towards people. They treated people with dignity and respect. There was a good atmosphere in the home.

People who lived on the first floor dementia unit had more opportunities than those on the ground floor to engage with staff on a social level, and to participate in activities.

The premises and equipment were safe for people to live in and use. The building was underg

This inspection took place on 16 November 2016 and was unannounced. Norton Grange Nursing and Residential Home provides care and accommodation to a maximum of 27 older people. On the day of our inspection there were 24 people who lived at the home. The home provides care and nursing support to older people and people who live with dementia.

The service was last inspected on 4 and 5 December 2015. At that inspection we found there were four breaches in the legal requirements and Regulations associated with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

These breaches were in relation to the care and treatment people received. People did not experience person centred care and their emotional and social needs were not met. Risk assessments did not clearly inform staff how to minimise a person’s risks and were not always carried out in accordance with the Mental Capacity Act. Staff had not followed the most up to date nutrition and hydration assessments for each person, and people did not have a choice of meals. Medicines were not always managed safely. There were not enough suitably trained and knowledgeable staff to meet people’s needs, and staff had not received supervision and training to help them undertake their roles effectively. Some staff recruitment practice was not robust.

Since our last inspection the manager 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 this inspection on 16 November 2016, we checked that improvements had been made. We found sufficient action had been taken in response to the breaches in Regulation, but there were still some areas where improvements were needed.

Staff were more responsive to the individual needs of people in the way they communicated with people, but there were still not enough daily activities which met people’s individual interests or needs.

There were usually enough staff to keep people safe, however the home continued to need to use agency staff to ensure there were sufficient staff to meet people's complex needs. The registered manager tried to ensure the same agency staff were used to cover gaps in the rota. Sometimes the gaps in the rota were not met at the week-end. This meant staff could not be responsive to people’s needs at all times.

The registered manager had notified us of incidents which affected the safety of people who lived at the home, but did not know how many people who lived at the home had a Deprivation of Liberty Safeguard in place, and had not, as required, notified us of those who did.

The provider had not undertaken their regulatory responsibility of publishing their last CQC rating on their website. People and their relatives had not, when looking at their website over the last year, been provided with an opportunity to find out what the issues were in the home.

The registered manager and deputy manager worked well together to support the home. Since our last visit, the provider’s regional manager had provided regular support to the registered manager, and the commissioners of the service had supported the provider to improve service provision.

Staff were caring and supportive to people and respected their dignity and privacy. Good relationships had been formed between people and staff. Visitors were welcomed at the home during the day and evening.

Since our last inspection, staff had received improved training and support in their roles to keep people safe and to provide effective care. Staff recruitment practice had improved and now minimised the risks of employing unsuitable staff.

Staff understanding of the individual risks associated with each person’s care and risk assessments had improved. Appropriate risk assessments been carried out to support staff in re

This inspection took place on 3 and 4 December 2015. The inspection was unannounced.

Norton Grange is a nursing home which provides nursing care and specialist dementia care for a maximum of 27 people. The home provides care on two floors. People whose primary care need is dementia, are mainly supported on the first floor, and people with more complex nursing needs are mainly supported on the ground floor. Twenty three people were living at the home at the time of our inspection.

The home does not have a registered manager, however the manager has applied to the Care Quality Commission to be registered to manage the service. Like registered providers, registered managers 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 our last inspection in May 2014 the home was fully compliant. Since then, the home has been through a challenging period of time. The previous registered manager and deputy manager left, and the provider recruited a new manager to start in April 2015. The person recruited informed the provider a week before they were due to commence employment and after the provider had waited three months for them to give notice, they decided not to take up the post. The current manager started work at the home in May 2015 at a time when many staff had left or were leaving the home, and relatives had raised concerns about the care provided.

Since May 2015 the manager has worked with the relatives and staff to improve the care provided to people. However there continued to be concerns about staff numbers and staff deployment. This was because the home continued to use agency and bank staff to cover staff vacancies whilst recruiting permanent staff, and staff worked with people whose needs they were unfamiliar with.

Recruitment practice did not always meet the requirements of the Health and Social Care Act 2008 legislation to reduce the risk of recruiting unsuitable staff.

Staff were kind and attentive to people when they provided personal care. However, staff interaction with people was mostly when supporting people with care tasks. We saw little involvement between staff and people at any other time of the day. There were limited opportunities for people to be involved in social activities.

Care provided was not person centred. Staff did not always know the individual needs, preferences, interests and capabilities of people who lived at the home.

People who were independent, received food and fluids which met their nutritional and hydration needs. However, there was a limited choice of menu, and not all people who depended on staff to ensure their meals and drinks met their needs, received their meals and drinks prepared as advised by health care professionals to keep them safe.

Staff had received training but their training did not equip them with the skills to provide the ‘specialist dementia care’ service the provider had advertised they provided. We observed staff had not put into practice some of the training in areas of health and safety.

The manager understood their responsibilities and the requirements of the Mental Capacity Act and the Deprivation of Liberty Safeguards, however, care practice at times did not adhere to the principles of the Act, and DoLS had not been applied for people who required it. Permission needs to be sought when a person who does not have capacity has their liberty restricted.

There were mixed views from staff as to whether there was an open and transparent management culture.

Medicines were mostly managed safely, however some concerns about the management of people’s medicines were identified .People’s health needs were met, and they were referred to the appropriate health or social care professionals.

Relatives and friends were able to visit the home at any time in the day or evening.

Improvements had been made to the premis

During our visit we looked at records, spoke with people, their relatives, management and staff. They helped us answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led? Below is a summary of what we found.

Is the service safe?

People were treated with respect and dignity by the staff. People told us they felt safe. Safeguarding procedures were robust and staff understood how to safeguard the people they supported.

Systems were in place to make sure managers and staff learned from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve.

The service had proper policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLs.) Four people living in the home had DoLs safeguards in place. This meant people were safeguarded as required.

Is the service effective?

People's health and care needs were assessed with them or their relative. Where people required specialist equipment such as pressure cushions or mattresses, or slings for hoists, these had been provided. When people required support for specific health or care needs this support had been provided. For example, people with swallowing difficulties had been referred for support from the speech and language team to enable them to have nutrition and hydration which met their needs.

We noted relatives could see people in private and visiting times were flexible. One relative told us, "I visit the home at many different times of the day or evening."

Is the service caring?

During our visit we observed staff being kind and respectful with all people living at Norton Grange. Some people had behaviours which challenged other people and staff. We saw staff support them with respect and patience. One person told us, "The staff are nice." Another told us, "Most of the carers are very pleasant and hard working." Relatives told us, "The care has been fantastic, can't fault it...the place could do with an uplift but it's the care that counts."

Is the service responsive?

We saw by looking at records and by talking with relatives and staff that the service responded quickly to any changes in people's health and care needs. We saw staff had been deployed differently on the ground floor to respond to some of the behaviours which challenged and this resulted in a marked reduction in incidents. We also saw staff were responsive in contacting other health and social care professionals to meet people's changing health and social care needs.

Is the service well-led?

We saw the service worked with other agencies to ensure people received care in a joined up way.

We saw staff had a clear understanding of their roles and responsibilities and had undertaken training to support them with this. Quality assurance processes were in place. This helped to ensure that people received a good quality service at all times.

We saw the service had only received two complaints within a 14 month period. These had been addressed effectively. Relatives told us they were able to approach the manager if they had any concerns or queries.

We looked at the care and welfare of people living at Norton Grange. We saw people were being provided with good support to meet their care needs.

We observed staff support. We saw staff were kind and treated people with respect. Staff were observed to work well with people who displayed challenging behaviour.

We sampled care records and found they gave clear, up to date information about the care and treatment needs of people living at Norton Grange.

We looked at equipment, furnishings and fittings. We were satisfied equipment such as hoists and wheelchairs were well maintained, but we saw sofas and chairs in the communal lounge areas were in a poor state of repair.

We saw the home was clean, and there were systems in place to minimise the risks of infection.

We spoke with one person at length about their experience living at Norton Grange. They told us care was, “mostly pretty good.” Their friend who was visiting also told us it was, “So different here to the bad stuff you read in the papers.”

We spoke with staff. One staff member said to us, "I like it here, the carers are so experienced and supportive."

We looked at records. We saw records gave up to date and accurate information about the care and treatment needs of people. They also demonstrated that people were being protected through good recruitment practice, and through the maintenance of equipment.

We spoke with three people who live at Norton Grange, and five visiting relatives. All were very happy with the care and support either they or their relatives had received.

One person told us, “I’m happy here…I like the dinners…staff help when I need it.” Another person said, “It’s very good here, I’m very happy.”

A relative told us, “The care he’s received has been nothing short of brilliant – spot on.” Another said, “I’m really happy with things here, she (relative) has been the most contended and confident to speak out…she used to cry a lot at the other home.”

We saw people’s privacy and dignity being respected, and we observed staff take their time with people. Many people living at Norton Grange were not able to verbally communicate. We noted that staff had developed a good understanding of their needs.

We looked at how the service managed medication. We were satisfied it was managed competently and people were safe.

We looked at staff support systems. We were satisfied staff receive sufficient support to work effectively and safely with people living in the home.

We looked at how the service responded to any formal and informal complaints and were satisfied that complaints were taken seriously and responded to in a timely way.

We decided to check this service because information was shared with us that raised concerns about whether staff were suitably qualified and skilled to meet people’s needs safely. Concerns were also raised about the checks made when staff were recruited to make sure they were suitable to work with vulnerable people.

We made unannounced visits to this care home on Monday 31 October and Tuesday 8 November 2011.

There were 22 people using the service when we visited. On the day of our visits we toured the lounge and dining areas, corridors and several bedrooms.

We looked at three people’s care records and spoke with the manager, four nurses, three care staff and the activity co-ordinator. We also spoke with the cook and kitchen assistant. We had a telephone discussion with the Care Home Support nurse specialist from Coventry NHS.

Some of the people using the service at Norton Grange have dementia care needs, which meant they might have difficulty engaging in complex conversations with us. We spoke with 12 people who were using the service when we visited and spent time observing their experiences in the care home. We also spoke with the relatives of two people using the service.

People’s comments included:

“People are kept clean, fed and given drinks.”

“I feel safe here – that’s the biggest attraction of being here.”

We found that people using this service are treated respectfully and their care and welfare needs are met.

Improvements are needed to make sure staff get the training they require to meet the specialist needs of people using the service. This to make sure there continues to be enough skilled and competent staff on duty to meet people’s needs.

We are concerned that the service does not always carry out checks on staff before they start working in the home.

We have asked the provider to tell us the action they will take to address our concerns.