This inspection visit was unannounced and took place on 8 March 2017. At our last inspection visit in May 2016 we asked the provider to make improvements to the assessments they completed when people did not have the capacity to make decisions. The provider sent us an action plan in June 2016 explaining the actions they would take to make improvements. At this inspection, we found improvements had been made. The service was registered to provide accommodation for up to 34 people. People who used the service had physical health needs and/or were living with dementia. At the time of our inspection 32 people were using the service.

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 were supported to make choices and when required assessments had reflected the person’s capacity. Best interest assessments where then completed to ensure the decision was made in conjunction with the relevant people. The home had enough staff to support people’s needs. The staff employed had received a range of checks to ensure they were suitable to work in the home. The manager and provider had established a range of audits to support the improvements within the home. We saw feedback was sought from people and relatives and any areas raised had been considered and responded to.

People told us they had established positive relationships with staff who showed respect for them. People were able to choose the meals they wish to eat and special diets had been catered for to ensure people received the correct support for their nutritional needs. We saw that medicines were managed safely and administered in line with people’s prescriptions. Referrals had been made to health care professionals and any guidance provided had been followed.

Care plans provided details about the person’s life, preferences and how they wished to receive their care. People were encouraged and supported with activities they wished to engage in. There was a complaints policy which was available, however no one had felt the need to raise any concerns.

Staff felt supported by the manager and there was a clear process in place to cascade information about the service and the needs of people. Staff had received training and the manager was planning to invest in further training to expand the staff knowledge in supporting people that were living with dementia.

We saw that the previous rating was displayed in the reception of the home as required. The manager understood their responsibility of registration with us and notified us of important events that occurred at the service; this meant we could check appropriate action had been taken.

This inspection was unannounced and took place on 4 April 2016. The service was registered to provide accommodation for up to 36 people. People who used the service had physical health needs and/or were living with dementia. At the time of our inspection 34 people were using the service.

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.

The registered manager did not understand their responsibility to comply with the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). We were told some people lacked capacity in certain areas but capacity assessments had not been completed to show how people were supported to make those decisions.

Staff understood what constituted abuse or poor practice. There were systems and processes in place to protect people from the risk of harm. The provider determined the staffing levels based on people’s needs and the level of support they required. Medicines were managed safely and in accordance with good practice.

Staff received training to meet the needs of people living in the home and this was ongoing. Staff received training and support from experience staff as part of their induction in to the home.

People received food and drink that met their nutritional needs and were referred to other healthcare professionals to maintain their health and wellbeing.

Staff were caring in their approach, and offered support with aspects of people’s needs. Staff we spoke with had a good understanding of people’s support needs, and their previous life before coming to the home. People told us their dignity was respected.

Staff told us they felt supported and they received regular supervision, which enable them to identified areas of development or support. People felt confident they could raise any concerns with the registered manager and that they would be addressed.

There were processes in place for people to express their views and opinions about the home and we saw that their views and had been listen to and acted upon.

The home completed audits across all areas of the home and used these to reflect any trends or areas where improvements could be made. The provider worked towards awards to reflect good practice.

We found 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.

As part of this inspection we spoke with twelve people who used the service, four members of the staff team, the registered manager and the provider of the service. We looked at a number of records including people's personal records and records kept in relation to the management of the service.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask. This is a summary of what we found:

Is the service safe?

People told us that they felt safe living at The Grange and that they were treated well. One person explained: “The staff are lovely, I feel perfectly safe with them.” Another person told us: “I feel safe here, the manager is lovely and they have been very good to me.”

Risk assessments were in place. Those checked on the day of our visit showed us that the risks associated with people’s care had been assessed and measures had been put into place to reduce that risk. This showed us that people’s health and welfare was, wherever possible, protected.

Records kept to monitor how much food and drink people had taken during each day were up to date and repositioning charts (used for people unable to move themselves in bed) showed us that people were being assisted appropriately. This showed us that people were protected from the risk of malnutrition and the development of pressure sores.

Staff knew what to do if they suspected that someone was being abused. One staff member explained: “I would tell the manager straight the way, you can go to her with anything and everything.” Another staff member told us: “I would tell the manager, the residents always come first.”

People who used the service told us that there were enough staff on duty and their care and support needs were always met. One person explained: “I cannot praise them [the staff] enough for their help, I’ve become friends with them all.” Another person told us: “They are always there when you need them.”

Is the service effective?

We spoke with people who used the service and they told us that they were satisfied with the care and support they received. One person told us: “The care is excellent.” Another person explained: “I don’t want a fuss and they respect that, they don’t fuss me.”

Care plans provided staff with information about people’s care and support needs. It was clear from our observations and from speaking with staff, that they understood the needs of the people they supported. One person told us: “I wear what I want and it’s written down what time I get up, I can’t lie in bed and they know that.”

Is the service caring?

We observed staff going about their work. They treated the people they were supporting in a kind and caring way. They provided them with the time that they needed in order to carry out a task, whether that was assisting them with their meals or assisting them to use the bathroom.

Everyone spoken with told us that the staff were caring and thoughtful. One person told us: “I am blind and the staff always explain to me what they are doing, I am very satisfied.”

Is the service responsive?

Relevant professionals had been involved in people’s care. Records showed that visits had been arranged when someone needed to be seen by their doctor or by a district nurse. Other professionals involved in peoples care included opticians and dentists. Where a person had been identified as losing weight, the local dietician had been involved in their care. This ensured that the people who used the service received the care and treatment they needed.

A complaints policy was available. This was accessible to both the people who used the service and their visitors. A copy of the complaints policy was displayed in the reception area and a copy was kept in each person’s room. This enabled people to know their rights and show them how to make a complaint if they wished to do so. People told us that they knew who to talk to if they had a concern of any kind. One person told us: “I would talk to the manager, I can talk to her, she is very helpful.”

Is the service well-led?

An appropriate monitoring system was in place. This enabled the manager to regularly monitor and assess the service and ensure that people received the best service possible.

Staff had a good understanding of their roles within the service. They felt supported by the manager and they told us that they could to talk to her, if they had a concern of any kind. One staff member explained: “You can go to the manager, her door is always open.”

Regular meetings had taken place. Both for the people who used the service and the staff who worked there. This provided people with the opportunity to be involved in the service and have a say on how it was run.

We spoke with 14 people living at the home and two care workers. We observed care workers to be caring and responding to people’s needs during the visit. We noticed how well staff interacted with the relatives who visited.

Comments from people receiving care included, “help is available at night. All the care workers are very good. I do not think the waiting times are unusual. I am very happy here. I have my say and I am listened to”.

“I sometimes have to wait at night but they usually get me to the toilet in time. It seems better”.

“I am well cared for by all care workers. The girls do a wonderful job and I could not ask for more”.

People told us they were given choices and were allowed to change their mind about care and treatment. They told us they were given appropriate support when they needed this.

People’s comments about care and welfare were mostly positive. Some people told us their needs were not always being met in a timely way. Comments included, “Staff are very good and very caring, I could not ask for nicer staff”. “Sometimes waiting for help seems a little long. When they come to you they are always really kind and helpful”. “Sometimes I worry they may not come in time”. If people have to wait for help, this could reduce their dignity. This could mean their personal care needs may not be met on time.

People told us the food was nice and they were able to sit with their friends. We saw the food was presented in an appetising way.

We observed care workers using health care equipment. We saw people’s personal aids were well maintained. We saw efforts were made to provide sufficient equipment to support both staff and people using the service. This meant each person had the necessary aid to improve their quality of life.

Three people told us they would be supported by staff or by relative’s, to make a complaint if they needed to do so.

We asked an expert by experience person to join us on our visit to this care home as part of our visit. We spoke with eight people who live at the home during the visit.

Seven people told us they were able to get up and go to bed when they wished, eat what they wanted and engage in activities if they wanted. All the people we spoke with told us their values and beliefs were respected, for instance one person told us they enjoyed the opportunity of joining in church services.

Comments on care and the atmosphere of the home included; “it’s a lovely place to live. I’m very lucky”, “the people here are the best thing about the place”, “there’s always good company here.”

We observed a lunch time meal during the visit. Three people told us there were long waiting times during meal times. One person told us, “there is a lot of waiting from one thing to another.”

We observed people receiving their medications during a meal time. The care worker administered medications to people safely and appropriately.

Comments about staff included; “they (carer workers) will always help you. They’re really good”, “you can’t fault the staff”, “they (all staff) are very obliging and helpful”.

We saw that both staff and people’s care records were locked away and accessible when needed.

People told us they were happy and liked living at the home, and they were very pleased with the home following the refurbishment of the dinning area.

People told us they can go to bed when they like, and that they like having a cup of tea in bed first thing in a morning.

We were told the new wing was opened by a resident who had celebrating her 100th birthday.

People told us that they have flowers on mothers’ day and a drink to celebrate fathers’ day.

We observed staff being patient and respectful, ensuring people’s dignity and privacy were respected and maintained.

We were told that they provide “good entertainment and, that food is good, we always have a choice.”