Willoughby Grange Care Home is registered to provide accommodation, nursing and personal care for 38 older people and people who live with dementia. There were 36 people living in the service at the time of our inspection. The accommodation was on two floors. The ground floor that was called the ‘Garden Suite’ was reserved for 10 people who lived with dementia most of whom did not need nursing care.

The service was run by a company that was the registered provider. At this inspection the company was represented by one of their regional managers. 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. In this report when we speak about both the company (as represented by the regional manager) and the registered manager we refer to them as being, ‘the registered persons’.

At the last inspection on 25 March 2015 the overall rating of the service was ‘Good’. This summary rating was the result of us rating the domains ‘effective’, ‘caring’, ‘responsive’ and ‘well led’ as ‘Good’. However, we rated the domain ‘safe’ as ‘Requires Improvement’. This was because the registered persons had not always deployed enough care staff to ensure that people promptly received all of the care they needed.

At this inspection the overall rating of the service remained ‘Good’. This summary rating was the result of us rating the domains ‘safe’, ‘effective’, ‘caring’ and ‘well led’ as ‘Good’. As part of this ratings exercise in relation to the domain ‘safe’, we found that sufficient nurses and care staff had been deployed to ensure that people promptly received all of the assistance they needed. However, on this occasion we reduced our rating of the domain ‘responsive’ to ‘Requires Improvement’. This was because people had not been offered a suitable range of opportunities to pursue their hobbies and interests.

The present inspection was unannounced and was carried out on 8 September 2017.

Our other findings at the present inspection were as follows. Nurses and care staff knew how to keep people safe from the risk of abuse including financial mistreatment. People had been helped to avoid most preventable accidents and medicines were safely managed. Background checks had been completed before new nurses and care staff had been appointed.

Nurses and care staff had received all training and guidance and they knew how to care for people in the right way. People enjoyed their meals and were helped to eat and drink enough. They had also been supported to obtain all of the healthcare assistance they needed.

People were supported to have maximum choice and control of their lives by nurses and care staff supporting them in the least restrictive way possible. Policies and systems in the service supported this practice.

People were treated with compassion, respect and courtesy. Nurses and care staff recognised people’s right to privacy and promoted their dignity. People had been supported to access lay advocacy services and confidential information was kept private.

People had been consulted about the care they wanted to receive and had been given all of the assistance they needed. As part of this nurses and care staff had promoted positive outcomes for people who lived with dementia including occasions on which they became distressed. There was a system for quickly and fairly resolving complaints.

People had been consulted about the development of their home and quality checks had been completed to ensure that people received safe care. Good team work was promoted and staff were supported to speak out if they had any concerns about people not being treated in the right way.

Further information is in the detailed findin

The inspection took place on 25 March 2015 and was unannounced.

Willoughby Grange Care Home is registered to provide accommodation and personal care for up to 44 older people and people living with a dementia. The home has two areas, the main house for people with nursing care needs and the Garden Suite for people living with a dementia. There were 37 people living at the service on the day of our inspection.

There was a registered manager in post at the time of our 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.

At our last inspection in April 2014 we asked the provider to take action to make improvements to respecting and involving people, their care and welfare, the management of medicines, records and how they ensured the quality of the service. The provider sent us an action plan and told us that these actions would be completed by September 2014. On this inspection we found that the provider had not made all of the required improvements.

The Care Quality Commission is required by law to monitor how a provider applies the Mental Capacity Act, 2005 and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are in place to protect people where they do not have capacity to make decisions and where it is considered necessary to restrict their freedom in some way. This is usually to protect themselves or others. Two people living at the service had their freedom lawfully restricted under a DoLS authorisation.

People felt safe and were cared for by kind and caring staff. There were not always enough staff on duty in the morning to meet people’s indivuidual needs. People received their prescribed medicines safely from staff who had the skills to do so. Staff knew what action to take and who to report to if they were concerned about the safety and welfare of the people in their care.

People were supported by designated activity coordinators to maintain their hobbies and interests. People were involved in planning future social events including trips out.

People were given a choice of nutritious and well presented home cooked meals. There were plenty of hot and cold drinks and snacks offered between meals. People were supported to have enough to eat and drink and have a balanced diet.

Staff were aware of people’s choices and preferences. Staff had the skills to undertake risk assessments and plan people’s personal, physical, social and psychological care needs. Staff had access to professional development, supervision and feedback on their performance.

People had their healthcare needs identified and were able to access healthcare professionals such as their GP or dietician. Staff knew how to access specialist professional help when needed.

There were systems in place to support people and their relatives to make comments about the service or raise concerns about the care they received. People and their families told us that the manager and staff were approachable.

People told us they were well cared for. One person said, “I’m very happy, I get good care from lovely staff.” Another person said, “We have entertainment, we had a choir and singers.”

We undertook a Short Observational Framework for Inspection (SOFI) at lunchtime in the dining room in the dementia unit. We saw people were offered a choice of food. Care staff told people what food was on their plate. The atmosphere was calm.

We saw all equipment was clean and in good condition. We saw evidence that regular safety checks were undertaken.

We asked people if care staff had the skills to look after them. One person said, “Oh yes, they always know what they are doing.” Another said, “I’m very happy with the staff, they look after me well.”

We saw the staff duty rotas. We saw there was always a registered nurse on duty.

Care staff told us they were well supported to do their job. One said, “We are a good team and all work well together.”

As part of our inspection we spoke with several people who use the service and their relatives, and a selection of staff members.

People spoke positively about the care and support they received. They told us they liked living in the home and that they were supported to make choices and decisions about their care. They told us that staff listened to them and that staff and the manager were approachable if they needed to talk to them. Several people told us that they were involved in writing their care plans. They told us that staff asked them what they like doing and what names they want to be known by.

One person told us, “You only have to ask for help and they see to it straight away.” Another person said, “We have a forum and we discuss what we are doing and what we enjoy.”

We observed several residents taking part in individual and group activities. The activities coordinator spoke to everyone to find out how they wanted to pass their time. Several ladies were watching a movie of their choice together and drinking coffee. The home had entered a best kept garden competition and several people were discussing the organisation of buying plants and where to put them.

We saw that people who were more able to speak up for themselves received better support and care then those who could not. We were told how people felt they were able to make choices and decisions for themselves and encouraged to be as independent as they were able, but also saw that some people were not using their own wheelchairs and had problems getting staff attention.

People who use the service told us they feel safe in the home and one person said “I get worried about fire, they check the fire alarm works, it goes straight through to the fire station, and the doors close”.

The people we spoke with told us the staff were good at their work and seemed to be well trained. One person said, ““the management side is good, the nurses are good, the carers are good and the chef will cook something different for us, he is wonderful.”

We were told by people that use the service they felt listened to and that they thought residents meetings would be worthwhile.

The home had two areas; one mainly for people with nursing needs and a dementia unit, called The Garden Suite for up to ten people. Both areas had a lounge and a dining room and there was a conservatory off the dining room in the main part of the home.

The inspection team was made up of an inspector, a pharmacy inspector, a specialist nurse advisor for dementia care and an expert by experience. We set out to answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, discussions with people using the service, their relatives, the staff supporting them and looking at records.

If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

People told us they felt safe. We saw there were up to date evidenced based policies and procedures to support staff to keep people safe such safeguarding and Deprivation of Liberty Safeguards (DoLS).

We saw one person had a standard authorisation for a Deprivation of Liberty Safeguards (DoLS) in place. This meant staff could lawfully deprive this person of their liberty because it was in the person’s own best interest to keep them safe from harm.

Staff told us they had adequate equipment to safely move and handle people. However, we saw hoist slings were not allocated for individual use. This was putting people at risk of harm of cross infection.

We looked at the recruitment of new staff. This showed that the required recruitment checks into qualifications and experience were in place. This meant people were being supported by staff with the appropriate skills.

We saw there was a system in place to ensure that equipment was maintained and repaired by the maintenance person or an appropriate external service.

Is the service effective?

We looked at four care files. The care files we looked at showed risk assessments for areas such as medication, nutrition, falls and safe moving and handling had been undertaken before care had been planned. Most care plans reflected people’s care needs identified in the assessments.

We saw where people had a diagnosis of dementia, mental capacity assessments had not always been undertaken. We saw initial assessments recorded this needed to be done but there was no evidence of a mental capacity assessment in their care files.

Is the service caring?

We saw people were not always treated with dignity and respect by staff. We observed some people were not involved in discussion about their care. For example, we observed one person being transferred by hoist from their wheelchair to an armchair by two care staff. Care staff did not speak with the person other than to ask them to sit forward when they were placing the hoist sling behind their back and again when they removed the hoist sling. Care staff did not ask the person if this was okay with them, explain what they were going to do or ask if they felt comfortable and safe in the hoist. Throughout this procedure the staff talked to each other in loud voices about their duty rota and their personal life to the exclusion of the person.

We observed lunchtime. We saw one person being assisted by two care staff to sit at the dining room table. We heard one member of care staff say, “Don’t put your bum down yet sweetheart.” We heard another member of care staff say to their colleagues, “Soft ones first.” We were told they were referring to the type of diet some people had, such as soft or pureed food.

We also observed other care staff who did involve people in discussions about their care and gave them a choice. They spoke positively with them giving them encouragement and support to maintain their independence. We heard staff make positive comments to people about their appearance or ask after their wellbeing. A senior carer told us some staff were better at involving people in their care than others.

Is the service responsive?

We saw that people's individual physical, mental and social care and support needs were assessed but not always met. We saw people were not always given a choice of how they wished to spend their day.

Some people told us they had to remain upstairs in their bedrooms until the care staff were free to look after them downstairs. One person told us, “This is my home; I’m waiting to be taken downstairs.” The manager told us because there was no dining room or lounge upstairs people took their breakfast in their bedroom. The registered bank nurse told us, “When it’s safe they can go downstairs.” This meant people were not free to move about the home as they wished.

We saw a copy of the annual customer satisfaction survey for 2013. 37 forms were sent to relatives and 13 were returned. 82% of people who responded were positive about the staff. One of the feedback comments read, “Higher staffing levels and a permanent manager.” We saw the evidence on our visit this feedback had been actioned.

The manager showed us how regular checks are carried out to identify any problems with the safe handling of medicines in the home and the actions that had been taken to prevent them happening again. The last check had been carried out just before our inspection and had identified many but not all of the issues that we found.

Is the service well-led?

We saw recruitment practice was safe and thorough and all the required checks had been carried out before staff commenced their employment. A recently appointed member of bank staff told us all the staff and the manager had been supportive

All the staff we spoke with told us there were enough staff in the home to deliver care to people. The bank registered nurse on duty said, “There is enough staff on duty today. They are looking for more staff.” The Head of Care told us, “There are enough staff, it has improved recently.” A bank carer told us, “There are enough staff, allocations all get done.” However, they did acknowledge at times care was delivered in a task focussed way. They also told us, “The manager has been the nurse in charge, she mucks in.”