About the service:

Orrell Grange is a purpose-built care home providing accommodation, personal and nursing care, including specialist dementia care, for up to 36 older people. It is situated in a residential area of Bootle with nearby facilities including shops, pubs and public transport. At the time of our inspection, there were 27 people living at the service.

People’s experience of using this service:

All of the people who lived at the service and relatives we spoke with told us they could not fault the staff and the care they received was good. One person told us, “They will not leave me on my own if I have got no one to talk to." A relative told us, “We visited several homes but we were made welcome here the moment we walked through the door. This is not the most modern or plushest, but the care is the best.”

The registered manager had created an open, caring culture. All of the people who lived at the service, as well their relatives, felt welcome and some referred to the service as their “home”. The team had worked hard to make the necessary improvements to provide consistently good care across the service. We heard positive comments from everyone we spoke with and saw the service had received compliments.

People felt safe living at the service and relatives told us they knew their loved ones were in safe hands. The service had made improvements to health and safety checks and measures. Quality assurance processes were more robust and led to improvements. Staff assessed and monitored risks to people and acted on concerns. People’s medicines were managed safely overall. There were enough staff to meet people’s needs and people did not have to wait long to be assisted. The service was clean and hygienic.

Staff were competent in their role and felt well supported. The service had improved the review of restrictions on people’s liberties, in line with the Mental Capacity Act 2005. Staff supported people to eat well and drink enough. The service worked with a variety of health professionals to achieve good outcomes for people and promote people’s well-being.

We found that some records relating to people's medicines needed to be clearer with regards to cream applications, ‘as required’ medicines and fluid thickeners. We pointed out that when staff had acted to achieve good outcomes for people, this needed to be reflected throughout care documentation. Some information for people, such as menus, needed to be made more accessible, such as in larger print. The refurbishment of the service was ongoing, to redecorate and make it more dementia-friendly. We considered the issues we found were easily rectifiable and had not put people at significant risk. The provider and registered manager acted on our feedback straightaway and confirmed record-keeping improvements had been completed the day after our visit.

At this inspection we found that the service met the characteristics of Good in the three areas we looked at. We found the service was safe, effective and well-led.

More information is available in the full report, which is also on the CQC website at www.cqc.org.uk .

Rating at last inspection: Requires Improvement (10 November 2018)

Why we inspected:

At the last inspection, we found the provider to be in breach of Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Following our last inspection, the provider sent us an action plan and met with us, to tell us how they would improve the service and ensure breaches of regulations would be rectified.

We carried out this focussed inspection to see whether the provider and registered manager had followed their action plan and addressed the breaches we found at the last inspection. We inspected to see whether improvements had been made to the service in respect of it being safe, effective and well-led.

We found at this inspection that improvements had been made acros

This inspection took place on 1 and 3 October 2018. The first day of inspection was unannounced.

Orrell Grange is a purpose built care home providing accommodation and nursing care for up to 36 older people. It is situated in a residential area of Bootle with nearby facilities including shops, pubs and public transport. At the time of the inspection, there were 27 people living in the home. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

The home had a registered manager. A registered manager is a person who has registered with 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 our last inspection in August 2017, we found that the registered provider was in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The home had not always maintained the environment to ensure the provision of safe care and treatment. Staff had not always managed medicines safely. During this inspection we checked whether the service had made improvements.

We found the registered manager and staff had worked hard to better the safety and quality of care. However, aspects of the safety, effectiveness and governance of care were still not always robust enough to protect people. This meant that there was overall no change in the rating of the service. There was a continued breach of regulation, with regards to prevention of and response to risk for people. People’s safety needed to be managed better by the home and the registered provider.

However, we highlight there were also very good examples of care. We found an overall caring culture led by the registered manager, who was looking at further ways to improve. Staff we spoke to confirmed this. People and their relatives spoke highly about the registered manager and the service.

We found that the management of medicines had significantly improved. The provider was no longer in breach of Regulation 12 regarding this.

The home had acted on our concerns regarding people’s access to some parts of the premises and secured these. We found however that the registered provider had not always acted in a timely way on some risks to people identified by checks, assessments and the monitoring of people's health.

Care files showed staff had completed risk assessments to assess and monitor people's health and safety. We found that staff had not always taken appropriate action to protect people based on their monitoring.

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

More detailed systems than at our last inspection were in place to oversee the safety and quality of the service. However, there were again issues we found during our inspection that these checks had not picked up.

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

People told us they felt safe living in Orrell Grange and staff responded to their needs quickly. Staff were knowledgeable about keeping people safe and knew safeguarding procedures.

Staff recruitment was robust. People living in the home and relatives told us there was enough staff on duty to meet their needs and staff agreed. The registered manager had added an additional staff member to protect people better.

When people were unable to provide consent, the home had completed mental capacity assessments. The registered provider was supporting the registered manager to improve these. We saw a good example of the registered manager working with others in a person’s best interest. The service needed to review conditions fo

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

Orrell Grange is a purpose built care home providing accommodation and nursing care for up to 36 older people. It is situated in a residential area of Bootle with nearby facilities including shops, pubs and public transport. At the time of the inspection, there were 30 people living in the home.

A registered manager was 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 in March 2016, we found that the provider was in breach of regulation regarding care planning. During this inspection we looked to see whether improvements had been made and found that they had. Care plans were specific to the individual person and provided staff with sufficient detail to enable them to provide care based on people’s needs and preferences.

We found that planned care was evidenced as provided and all but one of the care plans we viewed had been reviewed regularly to help ensure they remained accurate. The provider was no longer in breach of regulation regarding this.

External contracts and internal checks were in place to help ensure the building and equipment remained safe. We found however, that the environment was not always maintained to ensure people’s safety. Vulnerable people had access to the staff room which contained a kettle and staff members personal belongings. There was also direct access to the laundry where we found a pot of tablets on the window sill that belonged to a member of staff. The laundry gave access into the garden which contained an open shed full of equipment used by the maintenance staff which could pose risks to vulnerable people.

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

Staff received medicine training and had their competency assessed. Medicines which required refrigeration were stored in a fridge; however the fridge was not always maintained within the recommended temperature ranges. Records regarding medicines were not always maintained accurately as we saw gaps in the recording of administration and inconsistencies with the instructions for administration.

Systems were in place to monitor the safety and quality of the service, however they did not identify all of the issues we highlighted during the inspection. We made a recommendation regarding this.

People told us they felt safe living in Orrell Grange as staff were always available to support them when they needed it. Staff we spoke with were knowledgeable regarding safeguarding procedures and we found that referrals had been made appropriately.

We found that staff were recruited safely. People living in the home told us there was enough staff on duty to meet their needs and most staff we spoke with agreed. A twilight shift had recently been implemented to ensure there was enough staff to support people at busy periods throughout the day.

Care files showed staff had completed risk assessments to assess and monitor people’s health and safety. We found that appropriate actions were taken based on the results of these assessments.

People told us staff asked for their consent before providing care. When people were unable to provide consent, we saw that mental capacity assessments had been completed. Most of the assessments we viewed had been completed accurately and in line with the principles of the MCA. There was a system in place to seek and record consent, however this was not consistently followed.

Applications to deprive people of their liberty had been made appropriately.

Records showed that not all staff had received regular supervision to support them in their role. However, staff told us they felt

We carried out an unannounced comprehensive inspection of Orrell Grange on 3 and 4 March 2016, during which we identified breaches of regulation and issued the provider with warning notices. Concerns identified were in relation to medicines management, safety of the environment, staff support, care planning and monitoring of quality and safety within the service. The provider submitted an action plan detailing what improvements would be made to ensure compliance with legislation. We undertook this unannounced focused inspection on 22 September 2016 to see if the provider had made the necessary improvements to meet legal requirements. This report only covers our findings in relation to those topics. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Orrell Grange on our website at www.cqc.org.uk.

Orrell Grange is a purpose built care home providing accommodation and nursing care for thirty-six older people. It is situated in a residential area of Bootle with nearby facilities including shops, pubs and public transport.

During the inspection, there were 33 people living in the home.

A registered manager was 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.

When we carried out the last unannounced comprehensive inspection we identified concerns in relation to the management of medicines, safety of the environment and fire safety procedures. During this inspection we looked to see if the provider had made the improvements they told us they would make to ensure they were compliant with legislation and found that improvements had been made. Medicines were stored securely, records of administration were completed fully and stock balances we checked were accurate. We found that the provider had made improvements with regards to medicines management and legal requirements were met.

The registered manager told us that staff had undergone recent medicine training and had their competency assessed and we viewed records reflecting this.

At the last inspection we found that people were not always protected from risks relating to the environment. During this inspection we found that improvements had been made. We observed windows to be restricted where required for people’s safety and chemicals were stored safely within the home. The provider had implemented new systems to improve the quality and safety of the environment since the last inspection and were now meeting legal requirements in this area.

We found systems had been put in place since the last inspection to ensure fire safety checks were completed regularly and outstanding actions from the previous fire risk assessment had been addressed. Personal emergency evacuation plans (PEEPs) had been updated since the last inspection and provided detail as to what support each person would require should they need to evacuate the home in the event of an emergency.

The provider had implemented new systems to improve the quality and safety of the environment since the last inspection and were now meeting legal requirements in this area.

Although there were systems in place to seek and record people’s consent, we found that the principles of the Mental Capacity Act 2005 (MCA) were not consistently applied when people were unable to provide consent.

Records we viewed and staff we spoke with told us that since the last inspection, annual appraisals had been completed for all staff in post over 12 months.

A training matrix was available and this showed staff had completed training that the provider considered mandatory. A system had been implemented to ensure the registered manager was aware when training was due to be refreshed. We found t

This inspection took place on 3 and 4 March 2016 and was unannounced.

Orrell Grange is a purpose built care home providing accommodation and nursing care for 36 older people. It is situated in a residential area of Bootle with nearby facilities including shops, pubs and public transport. There were 33 people living at the home during the inspection.

A registered manager was 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.

People we spoke with told us they felt safe living in Orrell Grange and their relatives agreed. We found there were sufficient numbers of staff on duty to meet people’s needs and staff had a good understanding of safeguarding.

We looked at the systems in place for managing medicines in the home. People told us they got their medicines when they needed them, however we found concerns around the safe management of medicines. We observed a number of gaps in the recording of medicine administration. We found that the stock balance of medicines were not all correct.

We found that risk assessments had been completed with regards to the environment and equipment, however identified actions had not all been completed. Fire safety checks were not recorded as required and people’s emergency evacuation plans did not provide sufficient information to ensure staff could support them to evacuate the home. We referred our concerns regarding fire safety to Merseyside Fire Service.

The environment of the home was not maintained to ensure safety of all people. For instance, the window restrictors fitted to windows on the first floor, did not meet current requirements and we observed chemicals that were not stored securely within the home.

We found that staff were recruited in line with safe recruitment practices and ongoing monitoring of professional registrations was recorded.

Staff were supported in their role through induction and supervision. Appraisals had not been completed and not all staff had completed training in areas such as, safeguarding, medicines and fire safety.

We observed the home to be clean and personal protective equipment was available to staff and this was worn appropriately. There was hand gel available and bathrooms contained liquid soap and paper towels in accordance with infection control guidance.

We looked to see if the service was working within the legal framework of the 2005 Mental Capacity Act (MCA). We found that Deprivation of Liberty Safeguards (DoLS) applications had been made appropriately and staff were aware who this applied to within the home.

Care files we viewed showed that people had been consulted about their care and had given consent in areas such as photography, use of bed rails and information sharing. When people were unable to consent, a mental capacity assessment was completed and care was agreed by relevant parties in the person’s best interest.

People told us they enjoyed the food available and always had a choice of meal and that if they did not like either of the main meal choices, they could have an alternative. The chef catered for people’s dietary needs and preferences.

People living at the home told us staff were kind and caring and treated them with respect. We observed people’s dignity and privacy being respected by staff in a number of ways during the inspection, such as staff knocking on people’s door before entering their rooms.

Interactions between staff and people living in the home were warm and caring. We heard staff explaining to people how they were going to assist them before providing the support they needed and wished to receive.

People were involved in the creation of their care plans and plans we viewed reflected people’s preferences and

We spoke with people living at the home who said the staff communicated well with them and asked for consent on a daily basis when they gave personal care.

We were also able to make general observations of people's wellbeing and support. We observed staff asking people and explaining care to them before they carried it out. We saw many good examples of good communication.

During our observations we saw two people were seated in chairs and they were restricted by lap belts. Staff told us that this was a safety measure, as they may attempt to get out of the chair and walk, they might fall and injure themselves. When we looked at care records the assessments in place were not adequate to evidence people’s rights were protected with respect to any restrictive practice.

On the day of the site visit we spent some time observing the care and talking to people living in the home. We spoke with four people in some depth. They said staff supported them well. We saw there was good communication when staff carried out care.

People were relaxed and talked freely. Comments made were:

''The staff look after me very well. They are very kind.''

‘’Wonderful care’’

‘’Staff are here for all our needs’’

‘’Getting my hair done today. I get chiropody monthly. Would see matron if I had any worries’’

‘’There’s always staff around, they are very good’’

‘’The food is good, we always get a choice’’

‘’Staff are very good. They always make sure they spend time with us and are very patient.’’

‘’Staff are fantastic – they create a good atmosphere and are friendly.’’

‘’Staff always let me now what’s happening with [my relative] and let me know what’s going on. The care is good.’’

People reported staff numbers were consistent and staff said there was a good morale, so staff supported each other and worked well together.

We spoke with a relative who said staff worked well with them and reported any changes in the care quickly. They said the standard of care was consistent and their relative was being well cared for.

Those people spoken with were very relaxed around staff and said they were listened to, so any concerns were addressed. People, when asked, said they felt ‘safe’ living at Orrel Grange.

Orrell Grange provides accommodation and nursing care for thirty-six older people. It is situated in a residential area of Bootle with nearby facilities including shops, pubs and public transport.

This was an unannounced inspection which took place over two days on 31 July and 3 August 2015. The service was last inspected in July 2014 and was meeting standards at that time.

At the time of the inspection the previous registered manager had left the home. There was a new manager who had been in post for three weeks. They advised us they would be applying for registration. 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Arrangements were in place for checking the environment to help ensure it was safe. There was a new management team in place since the last inspection of the home. The managers had carried out a review of the home’s environment and identified that there were areas that required improvement.

When asked about medicines, people said they were supported well. We saw there were systems in place to monitor medication safety and that staff were trained and assessed to help ensure their competency so that people received their medicines safely. We identified some areas of medication management that needed to be improved. These included the accuracy of some records, monitoring of people on medicines that were given when necessary [PRN] or where there was choice of dosage. We also discussed the need to review and develop the medication auditing [checking] tool in use to help ensure issues were more clearly identified.

When we spoke with people living at Orrell Grange they told us they were settled and felt safe at the home. The staff we spoke with clearly described how they would recognise abuse and the action they would take to ensure actual or potential harm was reported. All of the staff we spoke with were clear about the need to report any concerns they had.

To support the 32 people living in the home on the days of the inspection there was a minimum of two nurses, seven care staff and the manager currently working supernumerary to these numbers. The care staff were supported by ancillary staff such as a chef /cook and other kitchen staff as well as domestic staff daily. Staff reported these numbers had been consistent although there was some concern expressed that staff had left following the recent change in management. They were unsure what this meant for future staffing. We were told by managers that there was a staff analysis underway and this would be based on measuring the dependency of people living in the home and matching this to a staffing ratio. This process would continue to be developed.

We looked at how staff were recruited and the processes to ensure staff were suitable to work with vulnerable people. We saw the required checks had been made so that staff employed were ‘fit’ to work with vulnerable people.

We looked at whether the home was working within the legal framework of the Mental Capacity Act (2005) [MCA]. This is legislation to protect and empower people who may not be able to make their own decisions. We found examples of good practice in supporting people with decisions in their ‘best interest’ when they lacked capacity but this was not consistent and showed staff varied in their knowledge and understanding.

We were informed on the inspection that the home supported two people who were subject to a Deprivation of Liberty Safeguards authorisation [DoLS]. DoLS is part of the Mental Capacity Act (2005) and aims to ensure people in care homes and hospitals are looked after in a way that does not inappropriately restrict their freedom unless it is in their best interests. We found there was uncertainty regarding the legal status of one of the people and previous management had not reviewed this appropriately or submitted statutory notifications to inform the Care Quality Commission of the DoLS authorisations.

People told us the meals were good and well presented. We observed and spoke with people enjoying breakfast and lunch. We were told that there was choice available with meals.

We asked people if staff were polite, respectful and protected their privacy and dignity. We received positive responses. We looked at how staff supported people to use the toilet. We had received information prior to the inspection that people’s privacy was compromised because the toilets near the lounge area were not suitable for people with high levels of disability. Managers told us they had identified this issue and there were plans to address this by developing the facilities.

People told us that staff generally responded to their care needs in a timely manner but we also found examples of staff not responding appropriately at times.

We received some concerning information before the inspection from relatives who were concerned that changes were being made to the home by the new managers and these were not being communicated effectively and people’s opinions where not being taken into account. The relatives concerned felt unsure about the future of the home. We found there was a need to develop better systems of communication and feedback to get people’s opinions about the homes development.

There was some information available in the home for people. We discussed some key information such as the complaints process and access to information regarding advocacy services. We were sent an updated copy of the homes ‘Statement of Purpose’ which provided accessible information; for example, regarding the complaints procedure and contact addresses for advocacy services.

We found people and their relatives were not fully involved in planning their care to help ensure it was more personalised and reflected their personal choices, preferences, likes and dislikes. We looked at the care record files for people who lived at the home. We found that care plans and records lacked recording of this information. There was minimal information about the social background, families, hobbies and interests of the people we reviewed. There was very little evidence in care plans reviewed of any communication with family. Relatives we spoke with said they had to ask for information and were not routinely involved in any care planning reviews. We saw one care record that had been recently audited to include more personalised information and reviews. We were told this standard was to be introduced with all people to help ensure a more consistent standard of personalised care.

We found the level of social activities in the home had reduced and people were not being provided with adequate planned social stimulation and activity during the day. The manager’s action plan had identified this and told us some of the plans to develop this aspect of care.

We saw a complaints procedure was in place and people, including relatives, we spoke with were aware of how they could complain. We saw an example of one complaint that had been received and dealt with recently. This had been responded to appropriately.

The manager was able to evidence a series of quality assurance processes and audits carried out internally. We found some of these were not currently developed to ensure the most effective monitoring. For example the way accidents and incidents were recorded and monitored was confusing resulting in the manager not being aware of incidents occurring over the last few months. Currently there was no system for auditing these to help ensure trends or lessons to be learnt were identified. We were shown a new accident audit tool which would be used for this purpose.

Other auditing tools such as the medication audit and dependency assessment tool [used to measure the nursing dependency levels of people in the home and link this to adequate staffing] and infection control audits still needed further development.

At the time of the inspection there was a new management team in place. During the inspection we discussed some of the issues arising from this change. Because of the impact of the changes at the home we were aware, prior to the inspection, of unrest amongst some staff and also relatives of people living at the home who had contacted us. Managers agreed to introduce more communication systems such as group and face to face meetings, especially with relatives and people living at the home to ensure the changes were communicated effectively.

We found that the home had not notified us of people who had been placed on Deprivation of Liberty [DOLS] authorisations.

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