We inspected The Grange Nursing Home on 18 June 2018. The Grange Nursing Home 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 service was registered to accommodate up to 29 older people, with age related conditions, including frailty, mobility issues and dementia. On the day of our inspection there were 24 people using the service; 11 had been assessed as requiring nursing care and treatment and 13 residential care and support.

The service was last inspected on 16 February 2016; no concerns were identified and the service was rated ‘Good’ overall.

There was a registered manager in post, who was present on the day of the inspection. 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 received care and support from staff that were appropriately trained and competent to meet their individual needs. Staff received one-to-one supervision meetings with their line manager.

People’s needs were assessed and care plans provided staff with clear guidance about how they wanted their individual needs met. Care plans were personalised and contained appropriate risk assessments. They were regularly reviewed and amended as necessary to ensure they reflected people’s changing support needs.

There were policies and procedures in place to guide staff on how to keep people safe from harm and staff showed a good understanding of their responsibilities.

People were supported with patience, consideration and kindness and their privacy and dignity was respected. People were protected from potential discrimination as staff were aware of and responded effectively to their identified needs, choices and preferences. People’s individual communication needs were assessed and they were supported to communicate effectively with staff.

Thorough staff recruitment procedures were followed and appropriate pre-employment checks had been made.

Systems were in place to ensure medicines were managed safely in accordance with current regulations and guidance. People received medicines when they needed them and as prescribed.

The registered manager worked in cooperation with health and social care professionals to ensure people received appropriate healthcare and treatment in a timely manner. People could access health, social and medical care, as required.

The provider was meeting the legal requirements of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People were provided with appropriate food and drink to meet their health needs and were happy with the food they received. People’s nutritional needs were assessed and records were accurately maintained to ensure people were protected from risks associated with eating and drinking. Where risks to people had been identified, these had been appropriately monitored and referrals made to relevant professionals, where necessary.

The provider had systems in place to assess the quality of care provided and make improvements when needed. People knew how to make complaints, and the provider had a process to ensure action was taken where this was needed. People were encouraged and supported to express their views about their care and staff were responsive to their comments and views.

This inspection took place on 16 February 2016 and was unannounced.

Accommodation for up to 29 people is provided in the home over two floors. The service is designed to meet the needs of older people. There were 23 people using the service at the time of our inspection.

At the previous inspection on 16 and 18 June 2014, we asked the provider to take action to make improvements to the areas of care and welfare of people who use services, management of medicines, assessing and monitoring the quality of service provision and records. We received an action plan in which the provider told us the actions they had taken to meet the relevant legal requirements. At this inspection we found that improvements had been made in all areas.

There is a registered manager and she was available during the inspection. 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 felt safe in the home and staff knew how to identify potential signs of abuse. Systems were in place for staff to identify and manage risks and respond to accidents and incidents. The premises were managed to keep people safe. Sufficient staff were on duty to meet people’s needs and they were recruited through safe recruitment practices. Safe medicines and infection control practices were followed.

Staff received appropriate induction, training, supervision and appraisal. People’s rights were protected under the Mental Capacity Act 2005. People received sufficient to eat and drink. External professionals were involved in people’s care as appropriate. People’s needs were met by the adaptation, design and decoration of the service.

Staff were caring and treated people with dignity and respect. People and their relatives were involved in decisions about their care. Advocacy information was made available to people.

People received personalised care that was responsive to their needs. Care records contained information to support staff to meet people’s individual needs. A complaints process was in place and staff knew how to respond to complaints.

People and their relatives were involved or had opportunities to be involved in the development of the service. Staff told us they would be confident raising any concerns with the registered manager and that they would take action. There were systems in place to monitor and improve the quality of the service provided. The provider was meeting their regulatory responsibilities.

During our inspection on 19 March 2013, we spoke with the manager, staff and people who used the service.

We observed and talked with staff who were very knowledgeable about the people who lived at The Grange and they demonstrated that they were able to understand their care and support needs. Care records and the training offered by the provider enabled staff to meet people’s health and care needs.

We received information from the infection control matron who had conducted a review of infection control at the Grange. Following the review the provider sent us an action plan to tell us they had carried out all the action that had been identified within the review. During this inspection, we found that all action had been taken.

We carried out this responsive inspection because we had concerns that this service had not been visited since 2009. During our visit we spoke with a number of residents who told us they were happy with the care and support they received from staff. One resident told us: “The staff are very good, they look after me well.”

Residents told us the quality of food was good. One resident told us: “The food is very nice, they give us a choice.” Another resident we spoke with told us: “The food is good I always get enough.”

Some of the residents we spoke with told us that they enjoyed some of the activities that were provided. One resident told us: “I enjoy going out when the weather is good. I have been on a boat trip and to the nature reserve. I have not been out since the summer.” We asked residents about their experience of being offered choice in their day to day life. One resident told us: “We always get asked about our likes and dislikes.”

All of the residents we spoke with told us that they were well cared for and protected by staff. One resident told us: “I feel safe here.” Another resident told us: “Staff look after us and protect us.”

During the inspection we spoke with five people using the service and asked them about their experiences of living at the care home. We spoke with two relatives. We also spoke with five staff, including the registered manager. We observed the care that was given to people. We looked at some of the records held in the service including the care records for seven people.

During the inspection we gathered information to answer five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service, their relatives and the staff told us.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

People using the service told us they felt safe. A relative we spoke with also told us they felt their family member was safe.

Staff had a good understanding of people's care and support needs. We observed the care for 45 minutes in the dining room at lunchtime. We saw people received appropriate and safe support.

However, we found that some care records did not provide appropriate information, for example, the eating and drinking care plan for a person using the service.

People using the service told us they felt that the care home was kept clean. One person said it was kept, “Very clean.”

People told us they were happy with the arrangements for their medication and got it on time. Relatives also told us they had no concerns about medication. We found that some actions had been taken by the provider since our inspection in February 2014 to make improvements regarding the management of medicines.

However, we saw some gaps on the topical medication administration record (TMAR) charts and we found that the instructions for staff were not always clear. We also found that the maximum temperature records for the fridge containing medication indicated that the temperatures had been too high for part of 39 days since March 2014.

We also saw that the medication administration record (MAR) charts and some other records about people using the service had not always been kept securely.

The Care Quality Commission monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We saw a DoLS policy was in place. The manager also understood their responsibilities regarding DoLS. However, two staff we spoke with did not have an understanding of DoLS.

Is the service effective?

Four people using the service told us they received the care that met their needs. Relatives told us they felt their family members received good care. One relative said, “I can’t express how happy I am for [family members] to be in here.”

However, we identified some concerns regarding the pressure area care for four people using the service. We saw that some care plans did not contain appropriate and consistent information about the support to be provided. We saw many entries on the turn charts that showed changes in position had occurred to protect people’s skin. However, we saw that some entries were not made in accordance with instructions in people’s care records.

A Mental Capacity Act (MCA) 2005 policy was in place. We saw some completed MCA assessments. We saw that most staff had received MCA training. The manager had also arranged for MCA training to take place in August 2014.

Is the service caring?

People using the service told us staff were kind and caring. One person said staff were, “Lovely.” Another person said, “Oh yes, they’re very kind.” Relatives also provided positive feedback regarding this. One relative said, “They [staff] are friendly.” Another relative said the care home was, “Home from home.”

We observed the care for 45 minutes in the dining room at lunchtime. We saw that staff communicated warmly with people as they supported them and staff were very caring and kind.

Is the service responsive?

One person using the service said, “They [staff] can’t help you enough.” Staff told us how they involved other agencies when appropriate.

However, we saw that records in May 2014 showed that a person had lost almost 5kg in weight since the previous month. The person’s weight had not been checked again prior to our visits in June 2014. We saw that the person’s eating and drinking care plan had been reviewed since the weight loss, but did not take account of the weight loss. We also saw that the nutritional risk assessment had not been completed before our inspection since February 2014.

Is the service well-led?

People using the service told us they felt they could have a say in how the service was run and they felt they would be listened to if they had concerns. One person said, “She’s [the manager is] very kind and she does listen.”

Staff told us they felt the care home was well run. Several staff members told us the provider visited regularly.

We found that improvements had been made since our inspection in February 2014 regarding how the quality of the service was monitored and risks addressed. However, we found that the systems in place to regularly assess and to manage risks relating to the health, welfare and safety of people using the service were not always effective. We found that some actions had not been taken where we had previously identified concerns.