This inspection took place on 2 and 3 January 2019. The first day of the inspection was unannounced. This meant the staff and provider did not know we would be visiting.

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

Washington Grange provides accommodation and personal care for up to 40 people, some of whom may be living with dementia. On the day of our inspection there were 36 people using the service.

At our last inspection we rated the service good. At this inspection we found the evidence continued to support the rating of good. There was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

Accidents and incidents were appropriately recorded and risk assessments were in place. The registered manager understood their responsibilities with regard to safeguarding and had been trained in protecting vulnerable adults.

The home was clean and suitably adapted for the people who used the service. Appropriate health and safety checks had been carried out.

There were enough staff on duty to meet the needs of people. The provider had an effective recruitment and selection procedure in place and carried out relevant vetting checks when they employed staff. Staff were suitably trained and received regular supervisions and appraisals.

Appropriate arrangements were in place for the safe administration and storage of medicines.

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 protected from the risk of poor nutrition. Care records contained evidence of people being supported during visits to and from external health care specialists.

People and visitors were complimentary about the standard of care at Washington Grange.

Staff treated people with dignity and respect and helped to maintain people’s independence by encouraging them to care for themselves where possible. Support plans were in place that recorded people’s plans and wishes for their end of life care.

Care records showed that people’s needs were assessed before they started using the service and support plans were written in a person-centred way. Person-centred means ensuring the person is at the centre of any care or support and their individual wishes, needs and choices were considered.

Activities were arranged for people based on their likes and interests, and to help meet their social needs.

The provider had a complaints policy and procedure in place, and people were aware of how to make a complaint.

The provider had an effective quality assurance process in place. People, visitors and staff were regularly consulted about the quality of the service via meetings and surveys.

The inspection took place on 14 and 16 June 2016 and was unannounced. This meant the provider did not know we were coming. Washington Grange was last inspected in July 2014. The service met all the regulations we inspected against at that time.

Washington Grange is a care home with accommodation for up to 40 people who require personal care, some of who are living with dementia. At the time of our inspection 39 people were receiving a service.

‘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 and relatives were complimentary about the service and made positive comments. They were happy with the care and support they received at Washington Grange. One person said, “I love them all, from the boss down over, everything about here is good.” One relative said, “I even wrote to the Chief Executive about the home to say how wonderful they are.”

Recruitment practices at the service were thorough and safe. Staff training was up to date and staff received regular supervision and appraisal. We looked at current and recent staffing rotas for the service. There were enough staff employed to make sure people were supported. Relatives told us their family members had the correct level of staff supporting them.

Staff had an understanding of safeguarding and whistleblowing and told us they would speak to

management if they had any concerns. They felt confident that management would listen and act on any concerns they raised.

Systems were in place for recording and managing safeguarding concerns, complaints, accidents and incidents. People and relatives told us they knew how to make a complaint. On person told us, “I would just tell them if I was not happy.”

Policies and procedures were in place to ensure medicines were managed in a safe way.

People’s health needs were regularly monitored and assessed. The service contacted other health care professionals when necessary, such as GPs and dieticians.

People had individual bedrooms which allowed privacy, these were comfortably furnished in accordance with people’s choices and preferences. We saw family photographs along with ornaments brought from home. One person had their own fridge in their room for storing snacks.

Staff understood the Mental Capacity Act 2005 (MCA) where people lacked capacity to make a decision and the Deprivation of Liberty Safeguards (DoLS) to make sure any restrictions were in people’s best interests.

People engaged in a variety of organised activities. They were supported by staff to maintain links with their family and the community by encouraging visitors into the home. Group activities and one to one sessions took place and the service had access to a minibus to facilitate day trips. We saw records of day trips and future planned outings.

People and their relatives told us they would feel confident to approach the staff or manager if something was wrong. Resident and relative meetings were held and an annual survey was used to gather feedback and opinions about the home and the service.

The manager completed regular audits and developed action plans which demonstrated they monitored the quality and safety of the service. The provider had oversight of the service with the regional manager conducting audits on a rolling programme.

People and relatives felt the management in the home was open and honest. One person told us, “I always sit here and [manager] always stops to have a chat, they leave their door open so you can see them.” One relative told us, “It’s a nice home, [manager] is really approachable, it’s like a little family really.”

Staff told us they were happy in their roles and enjoyed a good relationship with the people who lived at Washington Grange

We used a number of different methods to help us understand the experiences of people using the service. People we spoke with both individually in their bedrooms and in groups in the communal areas said they were "Very happy" with the service and staff were "Helpful and always willing to give a hand".

A relative told us they were confident their relative was being looked after; one said "I can’t fault them”, and another said their relative was “The best I’ve seen her for a long time" and they were “Always really happy with the care xxx gets". Staff were being supported to deliver the care and support through effective and appropriate training and supervision and were confident and competent to carry out their role. The staff were speaking to people in a kind and respectful way. We also observed that the people living in Washington Grange were clean and well groomed.

Patient records were detailed up to date and gave the staff information on how they could meet peoples needs. They were person centred, this means written to describe how a person would want their needs met and focused on them as individuals.

Washington Grange is a well maintained and decorated home which met peoples needs and gave them a pleasant place to live. The home was fresh smelling and pleasant. We looked at how the quality of the service was monitored and maintained. Records showed the manager takes the quality of the service seriously and makes sure improvements were made where necessary.

We used a number of different methods to help us understand the experiences of people using the service, because the people using the service had complex needs which meant they were not able to tell us their experiences.

Those people living in the home we spoke with, said that they were happy with the service provided by the staff. One person told us they had “No problems” and that they “Felt safe and well looked after”. another said “The staff are lovely”.

One visitor told us she thought the service was “Lovely” and she was “Over the moon” with the care her relative had received. She told us when her relative moved into the home (this was quite recently) they “Understood what if felt like” and although it was quite an “Upsetting day” they were made to feel very welcome and staff members took the time to settle them in. Another visitor, when asked about the care being given to their relative, said “The staff asked about my relatives likes and dislikes and have remembered things like how she likes her tea”. Both relatives had been involved in developing the care plan and were happy with the content of the document.

We spoke with a small group of people who were sitting in the lounge. They told us they were very happy with the service and how much they appreciated the staff and the manager. The told us the food was nice and one said “You should stay for your lunch because you can choose what you like”.

This out of hours visit took place to check whether improvements had been made following our findings from a visit to the service in September 2011.

We arrived at the home at 6.20am. We met with five people living at the service who all had varying degrees of dementia. Two people provided the following comments, “I’m warm and comfortable”; “I like my chair and my room”; “Yes I have slept well”; and “The staff are lovely”.

We met with over half of the people living at the service most of who had varying degrees of dementia. We spoke with six of the people who were up and dressed at 6.00am and found that several did not know what time it was. Several were unhappy and voiced their dissatisfaction. Their comments included; “I like to get up about 8 o’clock”, “I’m fed up and cold, what time is it?”, “I think I got up at 5am when the staff came in, I have had a wash” and “I didn’t want to get up”.

People who were using the service had complex needs which meant some were unable to tell us their views. Because of this we used a number of different methods to help us understand their experiences. We considered all the evidence we gathered under the outcomes we inspected. We used the information to answer the five 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?

We carried out our inspection over two days. 40 people were using the service. We spoke with 11 people who used the service and four relatives. We also spoke with seven staff and the manager.

Is the service safe?

Many of the people who lived at the home were unable to tell us their views because of their condition. We saw that people received appropriate care. We observed people enjoyed social activities and spending time with members of the staff team. Visitors were satisfied with the care being provided to their relatives.

We also sought the opinions of the local authority team which commissioned services from the home. They told us they had no current concerns about the service which had been rated ‘gold’ following a visit by the commissioners.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. An application had properly been made to safeguard one person. We found proper policies and procedures were in place. Relevant staff had been trained to understand when an application should be made and how to submit one.

We found appropriate arrangements were in place to manage medicines and we considered that people were protected from the risks associated with their use. Staff referred any concerns about medication side effects to people’s GPs. People and their relatives were satisfied with this aspect of their care.

There were enough qualified, skilled and experienced staff to meet people’s needs and the manager had increased the number of staff on duty in the early evening to help keep people safe. A visitor commented, "You can always find someone at the desk and one is walking about and another might be busy elsewhere. We've never observed anyone in need of care with no staff around.” Another told us, "I can't fault the staff there seems to be quite a few of them. My mum is satisfied with her care."

Is the service effective?

People and their relatives were happy with the care delivered. People told us, "It's comfortable," and “It’s ok here. You just get on with it.” A visitor told us, “I think he is being cared for pretty good."

We found that people received the care and support they needed. People’s needs were assessed and care and treatment was planned and delivered in line with their individual care plan.

Is the service caring?

We saw that people were treated with dignity and respect by staff, who were friendly and considerate. They were attentive to people and spent time talking with them to reassure and occupy them. For example, one visitor told us, "The staff calm my relative down. They talk to her all the time. She doesn't always co-operate (due to her condition). The staff handle her pretty well and explain what they are doing all the time."

There was a pleasant, welcoming atmosphere in the lounges where people spent time. We saw that people enjoyed social activities and time with staff. People who used the service told us they were well cared for. One person commented, “They’re all nice here.”

People expressed their views and were involved in making decisions about their care and treatment and daily lives. The staff promoted people’s independence and community involvement.

Visitors told us the staff were caring towards their relatives. One said, "It's absolutely smashing. The staff are very good."

Is the service responsive?

We saw throughout our visit that the staff enabled people to make choices and decisions relating to their care or treatment. Their representatives were also encouraged to be involved in making decisions about their care and treatment. One person who used the service told us, “There’s a good social life here, if you want it, but I prefer to stay in my ivory tower, and they let me do that.” This showed the service listened and acted upon people’s wishes.

Is the service well-led?

A manager was in place who was registered with the Care Quality Commission. People and relatives were confident about the way she managed the service. A visitor commented, "I think it seems to be run alright. We're in every day. I've never picked up on anything; even a little thing."

Another visitor told us, "If there was any problem we would just ask. The manager is very approachable. We've had no complaints."

Staff also felt supported. A care worker told us, “(The manager) is a nice person and approachable. She is all for the residents and all about people making choices.” Another said, “She is a lovely manager; very approachable.”

The service had a quality assurance system and we found that concerns were addressed promptly.