The inspection took place on 21 September 2018 and was unannounced, which meant that nobody at the service knew we would be visiting. At the last inspection in April 2015, the service was rated good. At this inspection we found the service continued to be good. However, the safe domain had deteriorated to requires improvement, this was due to environmental factors.

The Grange is a ‘care home. People in care homes receive accommodation and nursing or personal care as a 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 is an 18 bedded home providing care and support to older people. The home also provides care and support to people living with dementia. The home is a converted older property near the centre of Stockport.

At the time of our inspection the service had 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 2008 and associated Regulations about how the service is run.

The service was clean. However, the environment was tired and many areas were not well maintained to be able to be effectively cleaned. The registered provider following our inspection provided us with an action plan, this detailed the affected areas and showed the improvements required with dates for completion.

People told us they felt safe. Staff were knowledgeable regarding safeguarding and were aware of how to identify possible abuse and use the correct procedures to record and report. Risks associated with people’s care had been identified and staff were knowledgeable on how to manage the risks. Systems to manage medications were in place and followed.

We observed that although there were enough staff available to meet people’s needs this was not always in a timely way due to ineffective deployment of staff.

Accidents and incidents were monitored and the registered provider ensured lessons were learned.

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.

Staff received training on a regular basis. Staff were knowledgeable about their role. People received a nutritious diet. People had access to healthcare professionals and staff followed their advice.

We observed staff interacting in a positive way with people. People told us the staff were very kind and caring. Staff were observed to be kind and considerate, the interactions we saw was very respectful. People’s privacy and dignity was respected.

The care staff provided a range of activities took place. However, people told the activities could take place more often although when they were delivered they said they were very good. People told us they felt able to raise concerns and complaints and were listened to.

Audits were in place to ensure policy and procedures were followed. However, we found they were not always formally documented. The registered provider had identified this and was improving the systems.

There was evidence that people had a voice and were given opportunities to be engaged and involved in the home.

An inspector visited this service on 24 June 2014 to carry out an unannounced inspection. Prior to our visit we looked at all the information we hold on this service to help us to plan and focus on our five questions: is the service safe; is the service effective; is the service caring; is the service responsive; and is the service well led?

The summary is based on our observations during the inspection, speaking with people using the service, the staff supporting them, visiting relatives, a visiting healthcare professional and from looking at records.

Is the service safe?

During this inspection visit we observed that people were treated with respect and dignity by the staff and people told us they felt safe living in The Grange.

Each person had an individual care file that included risk assessments and a care plan that described how to meet individual care needs. The manager told us that since the last inspection visit in December 2013 all the care plans had been reviewed and rewritten. We saw evidence of this in the care files we looked at.

Visiting relatives told us that they were pleased with the care their relative received. They also told us they had never seen or heard anything that would cause them concern. One relative said “I have no complaints they look after (their relative) very well.”

Is the service effective?

During this inspection we saw the quality of food provided was of an acceptable standard. However we saw that choices were not given to people around the lunchtime meal. We did not see that people were consulted regarding the meal provided. We saw that everybody was given liver and onions, mash potato and mixed vegetables without being asked if that was what they wanted. Staff spoken with told us that it was a set menu and unless they knew the person did not like the meal provided then that was the meal served. This was discussed with the management team during this inspection.

During this inspection we spoke with a visiting health care professional who told us they didn’t have any concerns regarding the care delivered by staff. They said that the staff promptly and appropriately accessed their service for advice or treatment when required and staff carried out their instructions and recommendations.

We saw records to demonstrate that staff had received regular supervision and an annual appraisal which meant staff were supported to provide safe and effective care to people who lived in The Grange.

Is the service caring?

The atmosphere in the home felt relaxed, pleasant and friendly. From our observations we saw that care staff had a good understanding of people's individual needs and personalities. We saw that staff were kind and sensitive in their approach to people.

We observed that people looked well cared for and were appropriately dressed.

All of the people we spoke with who were living at the home indicated that they were happy and had everything they needed.

When we spoke with visiting relatives we were told that the staff delivered care in a kind and caring way. Some comments were: “All the staff are nice” and “They have got to know ‘X’ very well, they are very good with ‘X’.

Is the service responsive?

We saw that where appropriate the service had accessed advice and care from other health care professionals. For example we saw evidence of visits from the GP, the district nurse, the chiropodist, the opticians and we saw that people attended hospital appointments. This meant the provider sought relevant professional advice and guidance appropriately.

Is the service well-led?

The service was led by a manager that is registered with the Care Quality Commission.

Visiting relatives told us that they felt comfortable talking with the manager and one person said “The manager is lovely and makes me feel very welcome when I visit.”

We found that since the last inspection visit improvements had been made to the formal systems for assessing and monitoring the quality of the service provided.

We carried out this inspection to check that improvements required since our last unannounced Inspection on the 22 April 2013 had been made. Following that inspection the service had given us a report to show us the improvements that were going to be made. It was noted that not all areas of the report had been implemented.

We spoke with the registered manager, the joint provider and three members of staff. All the staff told us they were well supported by the management and felt that a high standard of care was delivered to people.

We found that staff had a better understanding of the homes whistleblowing policy and safeguarding adult’s policies and procedures than at the last inspection.

We saw some improvements had been made to care records however shortfalls were still identified.

There were still concerns because no formal auditing systems had been implemented to protect people from unsafe or inappropriate care.

During this inspection we spoke with 12 people who lived at the home and three visitors, the deputy manager and one of the providers of the service.

People we spoke with told us that they were happy and had no complaints. Some of the comments we received were: “This is a smashing home, the staff are great, really, really good, I have no complaints” “I can’t grumble I am very well looked after here,” “I am very happy with the care” and “The care is good, yes they do things the way I want them done.”

During our observations on the day of this inspection we saw staff providing care and support to people in a respectful way. We observed good interactions between the staff and people living in the home.

During this inspection we did have some concerns about the lack of detail in people’s plans of care. This means that people living at the home might not be protected from receiving unsafe or inappropriate care.

We found that some of the staff did not know where to find the home’s adult safeguarding policies and procedures and did not have up-to-date knowledge about safeguarding the people who used the service. This meant that people living at the home were not fully protected from the risk of abuse.

We had some concerns because there were no formal systems in place for assessing and monitoring the quality of the service provided to protect people from unsafe or inappropriate care.

We visited The Grange in June 2012 and spoke with a number of people who used the service.

They told us that they had no complaints about the home. Some of the comments we received were:- “The food is ok, feel safe and can talk to staff if I have any concerns;” “Staff help me get dressed and respect my privacy and dignity, give me my medication every meal time;” “If I am not happy about anything I can tell the manager;” “Very strange at first being with other people but now quite like it”.

We also spoke with the District Nursing service who told us that they felt that the new deputy manager who had recently been employed was very good and had made some changes and improvements in the short time she had been there.

There had been two safeguarding referrals since our last visit in August 2011. The staff from the Quality and Assurance section of Stockport Social Services had been involved with investigations. The allegations investigated were not substantiated.

People told us they liked living at The Grange and that they were happy with the service they received.

People told us they could choose what they ate and how they spent their time.

People told us that if they needed to see a GP or a district nurse this would be arranged for them.

People told us that care staff treated them well. One person said "it’s a nice place to live."

Other people told us that they enjoyed the food and meals provided at the service.

A relative told us they were very pleased with the care their mother received and that they had noticed "a big difference' in their relative who they described as being 'much happier."

People told us that care staff treated them well.

A relative described care staff and the home as, "Lovely staff and a good family environment."

People told us they always got their medication.

People told us that care staff treated them with respect and always listened to them.

This inspection was carried out over two days on the 1 and 2 December 2015. Our visit on 1 December was unannounced.

We last inspected The Grange in June 2014. At that inspection we found that the service was meeting all the regulations we assessed.

The Grange is a detached property situated in the Reddish area of Stockport, close to local amenities. The home is registered to provide care and accommodation for 18 older people. Accommodation is available on two floors. None of the bedrooms provide en-suite facilities but all have a wash hand basin. Access to the bedrooms on the upper floor is by means of a staircase, passenger lift or chair / stair lift. There are gardens to the front of the property and a small car park.

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 who used the service, who we asked, told us that The Grange was a safe place to live and that they were happy and well looked after well.

Staff we spoke with had a clear understanding of their role in protecting people and making sure people remained safe.

Care plans and risk assessments identified guidance for staff to follow about how to manage the risk(s) in order to promote and maintain people’s safety and also how to minimise risks to further promote and maintain people’s independence wherever possible.

Suitable arrangements were in place for the prevention and control of infection. During our tour of the building no unpleasant odours were detectable and all areas were found to be clean and hygienic.

Medicines were managed and safely administered by staff that had received appropriate training.

People who used the service, who we spoke with, felt care staff had the right level of skills and knowledge to support and provide them with effective care.

Staff completed induction training when they commenced working at the home, including familiarisation with the policies and procedures for the service.

People told us they knew who to speak to if they wanted to raise a concern or complaint.

People who used the service, who we spoke with, expressed satisfaction with the care and support provided by the service.

Staff gained people’s consent and cooperation before any care or support was offered or given. Where people were unable to give verbal consent, we saw that staff responded to the person’s facial expression or body language and responded appropriately.

Assessments had been carried out before the person had moved in to the home, to make sure that their identified needs could be fully met by the service. This information was then shared with the care staff to ensure they can personalise the care to meet the individual needs of the person.

People’s individual preferences and independence was promoted by the staff team and we saw and heard care staff encouraging people to make choices about their daily life style.

Activities were provided every afternoon by staff on duty.

People who used the service and their visitor’s told us that the registered manager and staff were very supportive, approachable and ‘nice to speak with’.

Systems were in place to monitor the quality of service being provided.

Members of staff we spoke with told us that the management team were very approachable and supportive.