We inspected The Grange Care Centre (Cheltenham) on the 11 and 13 December 2018. The Grange Care Centre (Cheltenham) provides accommodation, nursing and personal care to 60 older people and people living with dementia. It also provides short term respite for people. At the time of our visit 59 people were using the service. The Grange is located in the Charlton Kings area of Cheltenham. This was an unannounced inspection.

We last inspected the home on 6 and 8 November 2017. At the November 2017 inspection we rated the service as “Requires Improvement”. We found the provider was not meeting all of the requirements of the regulations at that time. People did not always receive care personalised care and were not always protected from the risk of infection. Care staff did not always have the training and formal support they required and the registered manager and provider did not have effective systems to monitor the quality of service they provided.

At this inspection, we found improvements had been made to the safety of the service and the provider’s quality assurance systems had effectively address some shortfalls. However, sufficient progress had not been made in relation to staff training and support and people’s person centred care. The provider was aware of these concerns and had a plan in place to improve the quality of care people received.

At this inspection, we found similar concerns in relation to staff training and support and in relation to people’s person-centred care. The provider was aware of these concerns and had a plan in place to improve the quality of care people received.

A registered manager was not in position at the service. The deputy manager and clinical lead were providing day to day management at the home, with the support of the provider until the new manager was in post. A new manager was in the process of being recruited by the provider. 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 did not always receive person centred care or meaningful engagement from care and nursing staff. Some care staff did not always ensure people received care which was tailored to their individual needs and preferences. People’s life histories and interests did not always inform their care plans and the activities they would enjoy.

People, their relatives and staff felt staffing had improved at the Grange Care Centre. There was a high level of agency usage which staff and people’s relatives felt impacted on some person centred care. The provider was taking action to address staffing concerns by carrying out recruitment. Care and nursing staff felt they were supported by the clinical lead and deputy manager. However, care staff informed us they did not always receive effective supervision and did not have the training they needed to meet people’s needs.

People were care for in a clean, safe and well-maintained home. The provider and manager carried out effective checks to ensure the service was appropriate for people’s needs. The provider had plans to refurbish the home in 2019. Nursing and care staff followed recognised infection control procedures.

People were protected from the risks associated with their care. Care and nursing staff knew how to assist people with their needs and ensure their health was maintained. People’s prescribed medicines were managed well.

Staff understood their responsibilities to protect people from harm and to report any safeguarding concerns. Staff provided people with choice and worked to protect and maintain their legal rights.

People had access to a good variety of food and drink. Care and nursing staff treated people with dignity and ensured they had their nutritional support and their

We inspected The Grange Care Centre (Cheltenham) on the 2, 6 and 14 November 2017. The Grange Care Centre (Cheltenham) provides accommodation, nursing and personal care to 60 older people and people living with dementia. It also provides short term respite for people, including people who require rehabilitation support. At the time of our visit 58 people were using the service. The Grange Care Centre (Cheltenham) is located in the Leckhampton area of Cheltenham. The home is located closely to a range of amenities. This was an unannounced inspection.

We last inspected the home on 14 and 15 May 2017. This was a focused inspection which was prompted in part by the HM Coroner Gloucestershire issuing a Regulation 28 to the provider which required them to address some matters of concern as a result of the death of a person. We also followed up on a requirement notice from our October 2016 inspection in relation to the management of medicines. At the May 2017 inspection we rated the service as “Requires Improvement”. We found the provider was not meeting all of the requirements of the regulations at that time and we issued a warning notice against the provider and the registered manager in relation to Regulation 12. People’s risks were not always effectively addressed and acted upon to ensure their health and wellbeing. At our November 2017 inspection we found improvements had been made to ensure people’s needs were assessed and acted upon, however the service was not meeting the requirements of all relevant regulations.

A registered manager was in position at the service. 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 were not always protected from the risk of infection. Care staff did not act in accordance with national best practice guidance regarding the control of infection. People’s equipment was not always effectively cleans and maintained.

People did not always benefit from activities and stimulation which was appropriate to their needs or abilities. The service and its managers are task focused. They do not encourage or support staff to provide care and support in a compassionate and supportive way. Care staff did not always ensure people received suitable stimulation and engagement, including at mealtimes. People’s life histories and interests did not always inform their care plans and the activities they would enjoy.

People told us they were safe living at the home and enjoyed the meals they received. Care and nursing staff treated people with dignity and ensured they had their nutritional support and their prescribed medicines. Catering and care staff were aware of and met people’s individual dietary needs.

There were enough staff deployed to ensure people’s needs were being met, however concerns had been raised about leadership at weekends. However care staff did not always have the training and support they required to meet people’s needs. Staff did not always feel they had the communication they needed to ensure people’s day to day needs were being met. The registered manager was taking immediate action in relation to these concerns.

Care staff were aware of people’s health and wellbeing needs. Care staff treated people with dignity and responded when there were any concerns with their wellbeing. People and their relatives felt their concerns and views were listened to and acted upon. Relatives told us they were informed of changes and felt the registered manager was responsive and approachable.

The registered manager did not always have effective systems to monitor the quality of service provided at The Grange Care Centre while systems were in place to ensure people’s care plans were current there was not always effec

We carried out an unannounced comprehensive inspection of this service on 5 and 6 October 2016. At this inspection we found that people had not always received their medicines as prescribed. This was a breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breach. We undertook a focused inspection on the 14 and 15 May 2017 to check that they had followed their plan and to confirm that they now met legal requirements. At this inspection, we also followed up on concerns raised following a HM Coroner’s inquest in March 2017 and whistle blowing concerns we received in relation to staffing levels within The Grange Care Centre (Cheltenham). This report only covers our findings in relation to these topics. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘The Grange Care Centre (Cheltenham)’ on our website at www.cqc.org.uk’

The Grange Care Centre (Cheltenham) provides residential and nursing care for up to 60 older people. 58 people were using the service at the time of our inspection. Many of the people living at the home were living with dementia. This was an unannounced inspection.

The home has 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 and associated Regulations about how the service is run.

At our focused inspection on the 14 and 15 May 2017, we found that the provider had followed their plan and the legal requirements in relation to the management of medicines had been met.

People mostly received their medicines as prescribed. Where mistakes in the administration of people’s medicines had occurred, nursing and care staff took immediate action to ensure people were safe. The service maintained a clear record of people’s prescribed medicine stocks, and following our last inspection had reduced the amount of individual boxed medicines and sought advice from healthcare professionals. People’s prescribed medicines were stored securely.

In relation to concerns raised following the HM Coroner’s inquest we found people’s care needs were not always recorded effectively. Records relating to people’s healthcare needs, such as food and fluid and repositioning charts were not always consistently completed. Care plans did not always provide care staff with clear details on how to assist people with their healthcare needs.

There was enough staff deployed to meet people’s needs in the main however we raised concerns regarding levels of staffing at certain specific times with the registered manager and provider. We were informed of the immediate action that was being taken to address these concerns. We recommended the provider review their staffing levels against the dependency of people living at The Grange Care Centre (Cheltenham).

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what actions we told the provider to take at the back of the full version of this report.

We inspected The Grange Care Centre on the 5 and 6 October 2016. The Grange provides accommodation and nursing care to older people; many of the people living at the home lived with dementia. The home offers a service for up to 60 people. At the time of our visit 53 people were using the service. This was an unannounced inspection.

We last inspected the home in January 2016 and found the provider was not always meeting the regulations. We found people did not always receive their medicines as prescribed, were not always protected from the risks of infection and their care plans did not contain necessary information about their care. Staff did not always have the training and support they needed to meet people’s needs and the provider did not have effective systems to monitor and improve the quality of service people received. Following our inspection in January 2016, the provider issued us a plan of the actions they would take to meet these breaches in regulation. At this inspection we found some appropriate action had been taken but other actions were still work in progress. One breach had been repeated from our last 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.

People did not always receive their medicines as prescribed. We discussed this concern with the registered manager who took immediate action. People’s care plans were not always current and accurate. The registered manager had a clear plan in place to ensure all people’s care plans and risk assessments were reviewed and updated.

People and their relatives were positive about the home, the staff and management. People told us they were safe and looked after well in the home. Staff managed the risks of people’s care and understood their responsibilities to protect people from harm.

People benefitted from activities and person centred care. There was a friendly, pleasant and lively atmosphere within the home. People also enjoyed the time they spent with each other and staff and carrying out activities. People were offered choices about their day. People and relatives told us they felt listened to and able to raise concerns or suggestions.

People had access to plenty of food and drink and received a diet which met their needs. Staff ensured their on-going healthcare needs were met.

People were cared for by staff who had access to the training they needed to meet people’s needs. The registered manager had a clear plan for staff to have the training they needed and to professionally develop. All staff felt supported by the registered manager and provider.

Staff were supported by a committed registered manager. There were enough staff with appropriate skills deployed to meet the needs of people living at the service and support them with activities. Staff spoke positively about the home and the registered manager.

People and their relatives spoke positively about the management of the service. The registered manager ensured people, their relatives and external healthcare professionals’ views were listened to and acted upon. The registered manager and provider had systems to assess, monitor and improve the quality of service people received at The Grange Care Centre (Cheltenham).

We found one breach 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 this report.

We inspected The Grange Care Centre (Cheltenham) on the 28 January and 2 February 2016. The Grange Care Centre provides residential and nursing care for older people; many of the people living at the home had a diagnosis of dementia. The home offers a service for up to 60 people. At the time of our visit 58 people were using the service. This was an unannounced inspection.

We last inspected in May 2015 and found the provider was meeting all of the requirements of the regulations at that time.

There was not a registered manager in post on the day of our inspection. The previous registered manager had left in July 2015. A new manager had been appointed in November 2015 and they were in the process of applying to become the 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.

People did not always receive their medicines as prescribed. Care staff did not always keep an accurate record of when people had received their medicines. People were not always protected from the risks of the spread of infectious diseases as some people had to share some pieces of equipment.

Staff told us they felt supported; however staff did not have access to supervision and training to enable them to be confident in their role. There were enough staff to meet people’s needs, however they were not always suitably deployed round the home to meet people’s needs.

The home’s manager was implementing new activity plans which included specific activities for people living with dementia. Care staff spent time with people and talked with them about things which were important to them, however there was not always structured activities available to them.

People’s care plans were not always current and accurate. The provider was aware of this concern and was in the process of reviewing and updating people’s care and risk assessments.

The provider had not ensured that systems were in place and regularly undertaken to sufficiently assess, monitor and continually improve the quality and safety of the services provided. The manager had identified concerns regarding the quality and the management of the home and had implemented an action plan. They had a clear goal to improve the service and provide good quality dementia care to people living in the home. Staff were aware of this goal, and people and their relatives spoke positively about the new manager.

People felt safe and were cared for by caring, compassionate and supportive staff. Care staff supported people to celebrate important events in their lives, such as anniversaries and birthdays. Relatives spoke positively about the impact staff had on their and their love ones lives. Care staff treated people with dignity and respect when they assisted them with personal care and mobility. Care staff offered people choice, and ensured people were treated compassionately.

We found three 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 this report. We have also made a recommendation regarding staffing within the home.

When we visited in April we found that the provider had not made sufficient progress in two areas where improvements had been identified in February 2014. These areas were in respect of the management of medicines and assessing and monitoring the quality of service provision. We issued compliance actions and the provider submitted an action plan on the 12 June 2014. The purpose of the inspection was to check that the improvements had been made.

This inspection was carried out by one inspector and a pharmacy inspector. During the inspection we spoke with the manager, one qualified nurse, two care staff and the maintenance person. We spoke briefly with three of the 25 people who were in residence. We looked at three people’s care files, the medicine administration records and records in respect of audits completed. We used the information we collected during this inspection, to answer the five questions. Is the service safe, effective, caring, responsive and well-led?

Is the service safe?

Each person needed to be supported with their medicines. The clinical lead nurse had taken the responsibility for ordering medicines and this had eliminated supplies running out. People’s medicines were administered at the times they were due. Appropriate records were kept of medicines administered and these were regularly audited. Medicines were stored safely and there were suitable arrangements in place for the storage of controlled drugs. Any creams and ointments were applied as prescribed.

Where people needed to have bed rails to maintain their safety in bed, risk assessments had been completed and written consent was obtained from either the person or their relative.

Is the service effective ?

People we spoke with were unable to tell us about what it was like to live in The Grange but said “The staff help me in the mornings to get up and dressed” and “The staff know what they are doing”. Other people were not able to answer our questions because of their mental or physical frailty.

Is the service caring?

People received the care and support they need because of good assessment and care planning procedures. Those files we looked at had been completed in detail and provided specific information about they needed and wanted to be looked after.

Is the service responsive?

People received care, treatment and support that was personalised to their individual needs and took account of their needs, choices and preferences.

Is the service well-led?

A programme of regular checks and audits had been introduced and the provider was kept informed about how the service was running. Arrangements to ensure infection control and prevention measures were adhered to still need to be embedded as part of the on-going improvements for the service.

The inspection was unannounced. The service was inspected on three occasions in 2014, initially (February 2014) because there was serious concerns and we took enforcement action against the provider. We visited again in May 2014 to check that improvements had been made and again in September 2014 to ensure that the improvements had been sustained.

The Grange Care Centre (Cheltenham) is registered to accommodate up to 60 older people who have general nursing care needs and, or, are living with dementia. The facilities for people are spread over two floors and the home has level access in from the car parking area and lift access to the upper floor. On each floor there is one 10 and one 20 bedded unit. The third floor contains offices and the service delivery facilities. All of the bedrooms have an en-suite including a toilet and level access shower facilities. At the time of our inspection there were 56 people in residence.

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 and has the legal responsibility for meeting the requirements of the law; as does the provider.

We brought this planned inspection forward because we had concerns raised with us about a number of issues: the management of medicines, dignity issues, a member of staff working without appropriate pre-employment checks in place and care documentation being out of date.

Staff lacked understanding of the principles of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). The MCA provides the legal framework to assess people’s capacity to make certain decisions. DoLS provide legal protection for those vulnerable people who are, or may become, deprived of their liberty. DoLS applications had been submitted to the local authority for a number of people however the registered manager had not considered this for others. When people were assessed as not having the capacity to make a decision, best interest decisions were made and involved others who knew the person well but the appropriate records were not always completed correctly.

Care planning documentation and other care records were not up to date and accurate. Care plan reviews were on the whole not meaningful and often only recorded ‘no change’. However where changes to a person’s care needs had been identified in the review, the care plan had not been amended accordingly.

The registered manager and staff team were knowledgeable about safeguarding issues, took the appropriate actions when concerns were raised and reported promptly to the relevant authorities. All staff received safeguarding adults training. The appropriate steps were in place to protect people from being harmed.

Risks were assessed and appropriate management plans were in place. The premises were well maintained and all maintenance checks were completed. Staff recruitment procedures were safe and ensured that unsuitable staff were not employed. Medicines were administered to people safely although some very minor improvements were pointed out to practice.

Staff were provided with basic mandatory training to enable them to carry out their roles and responsibilities. New staff completed an induction training programme and there was a programme of refresher training for the rest of the staff. Care staff were encouraged to complete nationally recognised qualifications in health and social care.

People were provided with sufficient food and drink and those people who were identified at risk of malnutrition or dehydration were monitored. There were measures in place to reduce or eliminate that risk. Arrangements were made for people to see their GP and other healthcare professionals when they needed to.

The staff team had good working relationships with the people they were looking after. Relatives told us the staff were kind, hard working, friendly and always made them welcome when they visited. Staff paid attention to ensure that people’s privacy and dignity was maintained at all times.

People were able to participate in a range of different activities. External entertainers visited the home and there were opportunities for people to go out from the home and use local facilities and community based social functions.

People were encouraged to have a say about their daily living activities. There were regular resident and relative meetings and there was an opportunity for people to comment on issues as satisfaction surveys were sent out. People and their relatives felt able to raise any concerns they may have and felt they would be listened to.

There was a good management structure in place. Staff were well supported and staff meetings were held on a regular basis. There was a regular programme of audits in place which ensured that the quality of the service was checked.

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.