This inspection took place on 7 November 2017 and was unannounced.

Walsham Grange 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. Walsham Grange accommodates up to 75 people, some of whom may be living with dementia, in one adapted building. At the time of our inspection there were 34 people living in the home.

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.

At our last comprehensive inspection on 14 and 15 March 2017 we found that the service was not meeting the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider was in breach of the regulations for safe care and treatment and good governance. During this inspection the service demonstrated to us that improvements have been made and is no longer in breach of the regulations.

The CQC is required to monitor the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and report on what we find. Whilst MCA assessments had been carried out, decisions made in people’s best interests were not always documented. We have made a recommendation about this.

Staff received training relevant to their role and this training covered a number of conditions that people may be living with. Staff compliance with training had improved but there were still some staff that had not completed all of the mandatory training set out by the provider.

Staff had regular supervision with a senior member of staff where they could talk about any personal or professional concerns in private. New staff completed an induction and would shadow an experienced member of staff before they worked independently.

People were supported to maintain a healthy nutritional intake and risks relating to people’s nutritional intake had been identified and mitigated. People’s weights were monitored and where needed, people’s food and fluid intake was monitored to ensure that they were maintaining a sufficient amount of food and fluid.

Timely referrals were made to other healthcare professionals such as the GP or district nurses where concerns were identified about a person’s health or wellbeing.

People’s individual risks were identified and detailed risk assessments gave staff guidance about how to manage known risks. Environmental risks were routinely assessed and remedial action was taken when hazards were identified. Servicing of lifting equipment and utilities regularly took place.

There were enough staff on duty to support people and people’s dependency was reviewed on a monthly basis to ensure that there were enough staff to meet people’s care needs.

People’s medicines were stored, managed and administered in a safe way. Staff who were responsible for administering people’s medicines had received training in this area. Topical medicines such as creams and ointments were applied as prescribed and there were also safe practices around the application of pain patches.

The home was clean and tidy. There were a team of domestic staff who worked in the service who maintained a good standard of cleanliness. Staff were observed to be wearing disposable gloves and aprons where needed.

Accidents and incidents were recorded and analysed for any trends or patterns. Steps were taken to reduce further occurrences.

People were supported by staff who were kind and caring. Staff interacted with people in a warm and friendly manner and knew how to offer reassurance to people when they became distressed. Staff showed interest in people and kn

This inspection took place on 14 and 15 March 2017 and was unannounced.

Walsham Grange provides accommodation and care for up to 75 people, many of whom would be living with dementia. At the time of our inspection 34 people were living in the home.

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 service has been in Special Measures. Service that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

At our last comprehensive inspection on 5 and 6 April 2016 we found that the service was not meeting the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider was in breach of the regulations for safe care and treatment, staffing and good governance. This was the second time that the provider was not meeting the regulation for good governance and as a result we issued a warning notice. This informed the provider why they were not meeting this requirement. They were required to be compliant by 17 June 2016.

We conducted a focussed inspection on 9 August 2016 to see whether the provider had met the requirements of the warning notice. We found that the necessary action to meet this requirement had not been taken and we placed the service in special measures. We imposed conditions on the provider’s registration. The provider was required to send us information every month about how they monitored and assessed the service being delivered to people.

At this inspection on 14 and 15 March 2017 we found that improvements had been made and the service was no longer in special measures. However, we still had concerns relating to the regulations for safe care and treatment and well led and the provider remains in breach of these regulations. Full information about CQC’s regulatory response to any concerns found during inspection is added to reports after any representations and appeals have been concluded.

There was a system in place to monitor the level of care people required and this was adjusted according to people’s changing care and support needs. This also determined how many staff were required to meet people’s needs effectively.

Steps to manage and mitigate risks to people’s health were not always taken. People who were nutritionally at risk did not always receive care appropriate to their needs and food and fluid charts were not always completed. Some people were at risk of developing pressure ulcers and required repositioning to minimise the risk of one developing. People were not always repositioned according to the guidance in their care plans. Records relating to the administration of creams were not always complete and we could not be assured that people were receiving these as prescribed.

During the inspection we found that there was exposed pipework which posed a risk to people if they fell on it. We also found that there was no risk assessment in place for the staff who lived on site. When we raised these concerns both the provider and manager took immediate remedial action.

The service had made a number of improvements since our last inspection. People living in Walsham Grange, their relatives and the staff all spoke of the service improving. During our inspection on 5 and 6 April 2016 we found that there were not enough suitably trained staff to care for people. As a result, the provider was in breach of the regulati

The overall rating for this service is ‘Requires improvement’. However, we are placing the service in 'special measures'. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in special measures.

We carried out an unannounced comprehensive inspection of this service on 5 and 6 April 2016. Three breaches of legal requirements were found and a warning notice was issued in relation to one of them which involved the governance of the service. We gave the provider until 17 June 2016 to meet the legal requirements of this regulation.

We undertook this focused inspection to check that the service had undertaken changes to meet the legal requirements of this regulation. This report only covers the findings in relation to the warning notice. You can read the report from our last comprehensive inspection in April 2016, by selecting the 'all reports' link for Walsham Grange on our website at www.cqc.org.uk.

At this inspection carried out on 9 August 2016 we found that there were still considerable concerns in relation to the governance of the home. We have not changed the overall rating for this service as a result of this inspection as it was only undertaken to follow up our enforcement action. The service remains requires improvement and the domain for well-led remains inadequate.

Walsham Grange provides residential and nursing care for up to 75 people, some of whom may be living with dementia. Accommodation is over two floors with a number of communal areas. Since our last inspection in April 2016, the service had closed its Grant Hadley unit which catered for people living with dementia. Although there were still people living with dementia residing in Walsham Grange, they had moved into the main house following appropriate consultation. At the time of this inspection, 44 people were living at Walsham Grange on a permanent basis, some of whom required nursing care.

At the time of this inspection, the home had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 our previous inspection in April 2016, although the manager was in post, their application to become registered with the CQC was being processed.

At this inspection carried out on 9 August 2016 the registered manager was not available and the deputy manager was managing the home in their absence. The registered manager was due to be available on 15 August 2016 and we gave them the opportunity to submit any further information in relation to the warning notice up until 5pm on that day. Additional information was submitted within the timeframe given.

At the inspection in April 2016, concerns were identified that demonstrated that the provider did not have effective systems in place to monitor the quality and safety of the service delivered. This had resulted in some people receiving a poor service.

At this inspection we saw that although some improvements had been made, the service was still in breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 which relates to governance.

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Although additional processes had been introduced to monitor the quality and safety of the service the home delivered, these were not wholly effective. The service had failed to appropriately manage the concerns highlighted in this report. These included a lack of suitabl

This inspection took place on 5 and 6 April 2016 and was unannounced. It was carried out in response to concerns raised with the Care Quality Commission (CQC) and to establish whether improvements had been made since our last inspection.

Walsham Grange provides residential and nursing care for up to 75 people, some of whom may be living with dementia. Accommodation is over two floors and there is a separate wing called the Grant Hadley unit to cater for those people living with dementia. At the time of our inspection, 54 people were living at Walsham Grange on a permanent basis.

There was a manager in post who had been appointed in February 2016. At the time of our inspection, the manager had submitted an application to the CQC to become a registered manager; their application was being processed. 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 last inspected this service on 28 and 30 April 2015 where we found that the service was not meeting the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider was in breach of the regulations for person-centred care, need for consent and good governance. The service was also in breach of the Care Quality Commission (Registration) Regulations 2009. This was because they had failed their legal obligations to report events to the CQC that affect people’s safety.

Following the inspection in April 2015, the service sent us a plan to tell us about the actions they were going to take to meet the above regulations.

At our inspection in April 2016, we found four 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.

The service had appointed a new manager who had only been in post since February 2016. Although the manager had an open approach with us and told us the areas of the service that required improvement, the provider’s quality monitoring audits had not identified the issues highlighted in this report.

Medication management was not consistently safe. People did not always receive their medicines as the prescriber intended. The service had failed to maintain accurate and full records in relation to medicines administration and management.

The people who used the service, staff and visitors to the home were not protected from the risk of harm as the service was unable to produce risk assessments for the environment. Accidents and incidents were recorded and the manager had an overview of these. However, no formal analysis was completed in order to identify contributing factors or trends. This potentially put people at risk of harm. Individual risks to people had been identified, assessed and reviewed on a regular basis.

Staff knew how to identify and report potential abuse. The service had appropriately liaised with other agencies to manage identified concerns. However, the service did not always have the knowledge to take appropriate action to investigate those concerns and required guidance.

People’s social and leisure needs were not consistently met. Although staff interacted with the people they supported on a regular basis, little activities took place and some people told us there wasn’t enough to keep them occupied or stimulated.

People received enough to eat and drink and could request this anytime. People’s nutritional needs were met. However, the mealtime experience was sometimes chaotic and disorganised within the nursing and residential area of the home.

The CQC is required to monitor the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and report on what we find. People told us they had been involved in the planning of their care although this had not been consistently docume

A single inspector carried out this inspection. The inspection followed up on concerns we had found at our inspection carried out on 11 April 2014, and the question this inspection addressed was ‘Is the service safe in relation to the number of staff on duty?’

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

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

Is the service safe?

At our previous inspection carried out on 11 April 2014, we found that there were insufficient numbers of suitably qualified, skilled and experienced staff employed to effectively meet service user’s assessed needs. Adequate staffing levels were not being maintained and staff absences were not being covered. Staff rotas covering the period from 31 March 2014 to 13 April 2014 had shown that unplanned absences had left the service short of care staff on 11 out of the 14 days.

During this inspection, we gathered evidence by speaking with staff, observing care and support being provided to people in communal areas of the home and we obtained copies of staff rotas covering the period 19 May 2014 to 08 June 2014.

The staff rotas showed that staffing levels had been maintained to an adequate level throughout the three week period apart from two occasions when unplanned absences had occurred. We were told that three staff had been recruited and had started their employment since our last visit, with the recruitment programme continuing into the future. This was to ensure that sufficient staff were available to cover all shifts and any absences.

Our observations showed that there were sufficient staff on duty to provide care and support to people. People were being assisted by staff in a calm and unhurried way. People using the service were seen chatting with staff and they appeared relaxed and cheerful. Staff spoke kindly and politely to people and responded appropriately to what was being said to them.

We reviewed the evidence we had obtained during our inspection and used this to answer five key questions we always ask: Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

This is a summary of our findings. If you would like to see the evidence supporting this summary please read the full report.

Is the service safe?

The staff that we spoke to understood the procedures they needed to follow to ensure that people were safe. They were able to describe the various ways that people might experience abuse and the steps they would take if they had concerns that abuse was occurring.

We inspected the staff rotas which showed that there were not always sufficient numbers of staff on duty to safely meet the needs of people throughout the day. Staff were receiving training that was appropriate to their role and there was a training plan in place.

There were systems in place to learn from events such as accidents and complaints. Procedures were in place for dealing with emergencies.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to staffing.

Is the service effective?

People’s health care needs were assessed but they had not signed to show they were involved in writing their care plans. Health and risk assessments identified individual care needs. People were supported to be as independent as possible. One person told us, “Staff remind me to do things then I do them myself.”

People told us they liked living at Walsham Grange and that staff were kind and caring. Staff explained how they were able to communicate with people who were living with dementia and were not able to express themselves verbally.

Is the service caring?

People were supported by kind and attentive staff. All staff showed respect and encouraged people to be as independent as possible. One person said, “The staff are good and help me.” Another person told us, “I can get up when I want and carers help me to get washed and dressed.” People were relaxed in the company of staff and interactions were appropriate.

People told us they could spend their day where and with whom they pleased and staff assisted them to do this. Visitors were seen at the home throughout the day and were greeted in a friendly and welcoming manner by staff.

Is the service responsive?

People knew how to make a complaint if they were unhappy. The complaints process was displayed in the entrance hall. Where shortfalls or concerns were raised these were addressed.

People’s needs were assessed and reviewed on a monthly basis. Where changes occurred, the service referred to health professionals for advice and guidance. We spoke with a visiting health professional who described the link worker as co-operative.

Is the service well led?

The service worked well with other agencies and services to make sure people received their care in a joined up way.

There were quality monitoring systems in place although they were not routinely being signed when completed. Care records were assessed and reviewed each month by senior staff. Audits of the environment were taking place regularly and these records were up to date and showed that remedial action was taken where shortfalls were identified.

Staff were clear about their roles and responsibilities. They spoke of how they worked as a team with the needs of the person central to the work they do.

This inspection was unannounced and took place on 28 and 30 April 2015.

Walsham Grange provides care and accommodation for up to 75 people who may require nursing or dementia care. On the days of this inspection there were 52 people living at this home. The home is divided into two units, the nursing wing and the Grant Hadley wing that provides support for up to 12 people living with dementia.

This service is required to have a registered manager in day to day charge of the home and one was 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.

Some areas of the home were not safe and hygienic. Razors were found left in communal bathrooms and these posed a risk to people. Areas of the kitchen were dirty with spillages not cleaned up. Cups and beakers were heavily stained.

People and their relatives were not always involved in the assessment, planning and review of their care. People’s care plans were not focused on the needs of each individual. Some care records were not kept up to date to demonstrate that people received the care and support they needed when they required it.

The registered manager had not notified the Care Quality Commission about significant events affecting the care and welfare of people living at the home.

There were enough staff available apart from first thing in the morning when we noted that people needed to wait up to 20 minutes for assistance. Activity co-ordinators had been employed recently and were spending time assessing what activities people would enjoy taking part in. Care records did not reflect people’s interests and hobbies.

The Care Quality Commission is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) Deprivation of Liberty Safeguards (DoLS) and to report on what we find. The principles of the MCA had not been applied when assessing if a person should be deprived of their liberty and an individual approach was not being taken. Best interests' decision making processes were not in place.

People were provided with a varied diet and choices, special diets and preferences were catered for.

People were not always referred to by staff in a dignified way, with some staff referring to people by their room number rather than by their name. Staff were kind and polite when speaking to people.

Staff had started to work with people who agreed, to explore and write their personal history so that staff understood the person and their life choices better.

The complaints procedure was not clearly displayed and known to people. Those complaints received had been investigated and responded to the satisfaction of the complainant.

Staff felt well supported by senior staff although some described a blame culture existing within the service. Staff meetings took place but supervision sessions had not been and there were plans to restart them so that information could be shared within the staff group.

People and their relatives were asked for their views about the quality of the service but these were not always acted on in order to make improvements. Quality audits were taking place but did not always identify shortfalls in the service.

You can see what action we told the provider to take at the back of the full version of the report.