We undertook an unannounced inspection of The Grange Care Centre on 4, 5 and 6 September 2018.

The Grange Care Centre is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The Grange Care Centre can provide accommodation and nursing care for up to 160 people with general nursing needs and end of life care. The service had eight separate units, each of which have individual bedrooms with en-suite facilities and communal living, dining, bath, shower and toilet facilities. Support was provided for older people including those with dementia care needs, younger adults with a physical disability and/or mental health needs and people requiring care at the end of their lives. At the time of the inspection there were 151 people living at the care home.

We previously inspected The Grange Care Centre on 30 and 31 August 2017 and 4 September 2017 and we identified three breaches of regulations. These were in relation to person-centred care, safe care and treatment of people using the service and good governance. The provider was rated requires improvement in the key questions of Safe, Responsive and Well-led and overall. We carried out a focused inspection of the service on 5, 6 and 9 February 2018 and we reviewed the key questions of Safe, Responsive and Well-led. We found improvements in relation to person centred care. We found the continuing breaches of two regulations in relation to good governance and staffing. At this inspection, the rating for the service remains requires improvement. This means the provider has been rated as requires improvement since the August 2017 inspection.

Following the last inspection, we asked the provider to complete an action plan to show when they would meet the regulation. The provider’s action plan stated they would be meet the regulation by 2 July 2018.

At the time of the inspection there was a registered manager in post who has been at the home since August 2014. 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 found some improvements had been made to the way care staff were deployed to support people around the home but feedback we received, from both people using the service and care staff, identified they felt that at times there were not enough care staff deployed to care for people. We have made a recommendation about the deployment of care staff.

The provider had a medicines procedure in place which was followed by care staff in relation to the storage, administration and recording of medicines but we noted some care staff were not aware of how to safely handle cytotoxic medicines. We have made a recommendation regarding guidance on handling these medicines.

Records relating to people using the service did not always provide accurate information relating to the care and support they needed, so staff had all the information they needed to care for people

The provider had audits in place, but these did not always identify areas where improvement was required and where they had identified areas for improvement, action taken was not always effective in securing the necessary improvements.

People told us they felt safe when receiving care and the provider had procedures developed to respond to any concerns relating to the care provided.

Incidents and accidents were reviewed and the provider took action where required and provided guidance to staff to reduce a possible reoccurrence. Risk management plans had been developed providing care staff with information as to how to reduce possible risks.

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We undertook an unannounced focused inspection of The Grange Care Centre on 5, 6 and 9 February 2018. This inspection was done to check that improvements to meet legal requirements planned by the provider after our August 2017 inspection had been made. The team inspected the service against three of the five questions we ask about services: is the service safe? is the service responsive? and is the service well led? This is because the service was not meeting some legal requirements.

No risks, concerns or significant improvement were identified in the remaining Key Questions through our ongoing monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

The Grange Care Centre is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The Grange Care Centre is registered to accommodate up to 160 people requiring nursing or personal care. The service has eight separate units, each of which have individual bedrooms with en suite facilities and communal living, dining, bath, shower and toilet facilities. It caters for older people including those with dementia care needs, younger adults with a physical disability and/or mental health needs and people requiring end of life care. At the time of inspection there were 151 people using the service.

The service is required to have a registered manager in post, and the registered manager has been at the service since August 2014. 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 identified shortfalls with the staffing deployment and received feedback from people, relatives and staff that there were times when the service was short of staff. There were systems in place for monitoring the service, however we identified areas that needed more robust monitoring such as staff deployment and the electronic records system.

Since our last inspection, there had been improvements in the management of medicines to ensure people received their medicines safely. Staff recruitment procedures were in place and being followed. Risk assessments for individuals and for systems, equipment and safe working practices were in place and identified the action to take to mitigate the risks. People and relatives felt people were safe living at the service. Staff understood and followed safeguarding procedures. Protocols were followed to learn from incidents and accidents to help prevent reoccurrence.

Since our last inspection there had been improvements with the care records and care plans were now person centred and up to date. Activities were provided and people had mixed feelings about the activities provision as it did not always meet everyone’s needs. There was a complaints procedure in place and people and relatives felt able to raise any concerns. Records showed that any complaints raised were addressed appropriately. People’s wishes in respect of end of life care were discussed and recorded.

The registered manager was responsive to our findings and was able to gather information to answer anomalies found with the care records. The provider was actively recruiting for more staff and was aware that further work was required on the electronic records system so that the records consistently reflected the care and support that a person received.

There were systems in place for gaining feedback on the service provision. The registered manager was involved with projects with

The inspection was carried out on 30, 31 August and 4 September 2017 and the first day of the inspection was unannounced. During the last comprehensive inspection in June 2015 we found the service was meeting our regulations.

The Grange Care Centre provides accommodation for people requiring nursing or personal care for up to 160 people. The service has eight units, each with single en suite bedrooms, dining and sitting rooms and bath and shower facilities. At the time of inspection there were 156 people using the service.

The service is required to have a registered manager in post, and the registered manager has been at the service since August 2014. 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 identified some shortfalls in medicines management which could place people at risk of not receiving their medicines safely. We discussed this with the management team and they said they would address our concerns promptly.

Care records were not always personalised so did not reflect people’s individual care needs. Where people’s needs were not always being fully met, the reasons for this had not been explained in the care records.

Although the service had comprehensive auditing and monitoring processes in place, further work was needed to ensure medicines management and personalisation of care records were kept up to date.

Activities staff were available and activities programmes were in place and being followed. Work was ongoing to meet people’s diverse hobbies and interests and the need to keep the activities provision under review was understood by the registered manager.

Staff received safeguarding training and knew to report concerns. Staff recruitment processes were being followed so that only suitable people worked at the service. There were enough staff to meet people’s needs and staffing levels were kept under review.

Risks to individuals had been assessed and action plans were in place to minimise them. Risk assessments for equipment and safe working practices were in place to mitigate risks to people visiting and working at the service.

Infection control procedures were being followed to protect people from the risk of infection and keep the environment clean.

Staff received training to provide them with the skills and knowledge to care for people effectively. The service was meeting the requirements of the Deprivation of Liberty Safeguards (DoLS) and Mental Capacity Act 2005 (MCA).

People's dietary needs were being identified and overall they were being met, Feedback about the food was mixed and work was ongoing to ensure people were aware of the variety of food options available to them. People received the input from healthcare professionals, according to their needs and staff implemented any changes in care and treatment.

Staff treated people in a caring and gentle manner. They found out about people’s care needs and preferences and respected these. Staff treated people with dignity and respect.

The complaints procedure was available and people, relatives and staff were encouraged to express any concerns so they could be addressed.

The management team were receptive and worked hard to maintain a good standard of care provision at the service. Staff said the management team were approachable and supportive.

We found three breaches of regulations at this inspection. These were in regards to person centred care, safe care and treatment and good governance. You can see what action we have asked the provider to make at the end of this report.

We carried out a comprehensive inspection of this service on 25, 26 and 27 November 2014. Breaches of legal requirements were found. We took enforcement action by serving a warning notice on the provider requiring them to become compliant with Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, management of medicines, by 19 February 2015.

The provider wrote to us following the inspection to say what they would do to meet legal requirements for the breaches we found.

We undertook this unannounced focused inspection on 20 February 2015 to check that the improvements required for the most significant of the breaches had been made. We looked at the actions taken by the provider in respect of the breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. We will follow up the breaches found under other regulations at a later date.

We found the provider had addressed the breach of Regulation 13. Legal requirements for the management of medicines had been met. People were being better protected against the risks associated with the unsafe use and management of medicines. This report only covers our findings in relation to that requirement. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for The Grange Care Centre on our website at www.cqc.org.uk

The Grange Care Centre provides accommodation for people requiring nursing or personal care for up to 160 people. The service has eight units, each with single en suite bedrooms, dining and sitting rooms and bath and shower facilities. Two units accommodate people with general nursing care needs, one unit accommodates people with personal care and dementia care needs, one unit accommodates people with physical disabilities, one unit accommodates people with end of life nursing care needs, one unit accommodates people with behavioural and nursing needs and two units accommodate people with nursing and dementia care needs. At the time of the inspection there were 107 people using the service.

The service is required to have a registered manager in post, and the registered manager has been at the service since August 2014. 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 carried out this inspection after we received information of concern from an anonymous whistle blower. The whistle blower alleged staffing levels in the home were not sufficient to meet the care needs of people using the service and staff were not recording falls and accidents.

We spent time on two of the home’s units where the whistle blower told us they had concerns. We spoke with six people using the service, four members of staff, the home’s manager and two deputy managers. We also looked at staffing rotas and the care plans and risk assessments for 10 people and reviewed training information sent to us by the provider.

The people we spoke with told us they were happy with the care they received. Their comments included “excellent, I get all the help I need” and “the staff are very good, I can always get help when I need it.”

We saw the provider had systems to assess people’s care needs, including risks to their safety. Risk assessments were completed and regularly reviewed and where potential risks were identified, care staff were given guidance on how these should be managed.

There were sufficient staff to meet people’s care needs and the provider had systems in place to make sure adequate numbers of staff were provided in each unit, based on the dependency levels and care needs of people of people using the service.

There were procedures in place to record accidents and regular audits were carried out to make sure causes were identified and addressed. This meant the provider took action to learn from incidents.

At the time of our visit there were 128 people using the service.

We carried out two visits to The Grange Care Centre. One took place with three Compliance Inspectors on the 6th July 2012, and a further inspection by a CQC Pharmacist Inspector took place on 12th July 2012. During the first inspection we spoke to a number of people who lived within the units of each floor of the home. In total we spoke with eleven people on the ground floor, eight people on the first floor and three on the second floor. We also spoke with relatives who were present during our visit. On the second floor we also carried out a Short Observational Framework for Inspection (SOFI), which is where we observed a select number of people for a number of hours, recording their interactions, how staff supported them and how they spent their time during this period. Throughout all the floors and units of the home we observed what people did and a number of different interactions during our visit.

People were positive about the care and treatment they received at The Grange Care Centre, where they spoke about the good attitude of the staff and of getting the support they wanted for their needs.

People said they felt safe and that there were enough staff to meet their needs.

In the report we have highlighted areas that the provider might like to note, such as a lack of interactions during mealtimes on some units, a lack of meaningful activities on some dementia units and some unclear recording in the care notes. We also identified some minor concerns regarding the way medication was managed by the service.

People we spoke with told us staff used the hoists appropriately and safely. They were satisfied that staff assisted them with their mobility and with moving to various areas of the home according to their needs.

People and their friends and relatives told us that they were well looked after by the staff and (that) all individual needs were met. One visitor said “I would be very happy to live here when I can no longer look after myself”. A person living at the home told us, “Everyone treats me well”.

We did not speak with people using the service on this occasion. However, we observed that people were served with lunch in the dining room or their bedroom, according to their needs and preferences. We saw that people were supported to eat meals independently and that those who could not were assisted sensitively by staff to eat their meals in an unhurried manner.

During our inspection a relative raised a concern that there were not enough staff on one of the units. We also received a complaint from another relative on the same day that there were not enough permanent staff in the home.

However, we found evidence that the units were staffed with the appropriate numbers of staff with relevant qualifications to meet the needs of people using the service.

People told us that they enjoyed their meals and that they received the meal of their choice. We saw letters from residents praising the improvements in the quality of food since the new manager had introduced changes to the menu.

We were told by a relative of someone who used the service that their intake of fluid and food had not been sufficiently monitored and this had resulted in them becoming ill.

People who use the service and their relatives told us that they were happy with most aspects of the service. Some relatives were concerned about issues relating to personal care and a lack of interaction between staff and people using the service. People were happy with the food choices they were offered and the types of activities provided for them.

The inspection was carried out on 29 and 30 June 2015 and the first day of the inspection was unannounced. During the last comprehensive inspection in November 2014 we found a number of breaches of regulations. At a focussed inspection in February 2015 we found the provider had taken action to address the breach in medicines management. At this comprehensive inspection we found the provider had taken action to address the other breaches we had identified and standards of care for people using the service had improved.

The Grange Care Centre provides accommodation for people requiring nursing or personal care for up to 160 people. The service has eight units, each with single en suite bedrooms, dining and sitting rooms and bath and shower facilities. At the time of inspection two units were closed for refurbishment and people were accommodated in the other six units, with 103 people using the service.

The service is required to have a registered manager in post, and the registered manager has been at the service since August 2014. 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 this inspection we found improvements had been made in many areas to improve the safety and experiences of people living at the service. These improvements needed to be sustained.

People were happy with the service and we received positive feedback from people, relatives and visiting healthcare professionals, who felt the service had improved significantly and people’s needs were being met.

The service was being maintained and servicing and maintenance records were up to date. Risk assessments were in place for identified areas of risk, to minimise risks to people.

Staff recruitment procedures were in place and were being followed to ensure suitable staff were being employed at the service. The service was being staffed to meet people’s needs.

Safe and effective systems for medicines were in place, so that people consistently received their medicines safely and as prescribed.

Staff had received training and demonstrated an understanding of people’s rights, their individual needs and choices and how to meet them. Staff supported people in a gentle and professional manner, respecting their wishes and maintaining their privacy and dignity.

Staff understood safeguarding and whistleblowing procedures and were clear of the process to follow to report any concerns. Complaints procedures were in place and people and relatives said they were able to raise any issues so they could be addressed.

We found the service to be meeting the requirements of the Deprivation of Liberty Safeguards (DoLS) and Mental Capacity Act 2005 (MCA). DoLS are in place to ensure that people’s freedom is not unduly restricted. Staff listened to people and sought their consent when providing them with care and support.

Food and drink to meet people’s individual needs and preferences was provided and staff understood people’s nutritional needs. Staff recognised people’s changing needs and people received input from healthcare professionals when they needed it.

People were involved with their care records and these were person-centred and reflected people’s needs, interests and wishes. Systems were in place for the auditing of care records to identify any shortfalls so they could be addressed in a timely way.

People and relatives were consulted about the running of the service and they were listened to. The service took part in research projects to improve the knowledge of staff and the experience of people who used it. Systems were in place for monitoring the service and these were effective so action could be taken promptly to address any issues identified.