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

Windermere Grange accommodates 50 people over two floors and within four separate wings. The service had two specialised services which provided care to people living with dementia and care and support for people with learning disabilities.

The learning disability service was situated off the main residential home with its own secure entrance. At the time of the inspection there were 14 people living in the service. The size of this service is larger than current best practice guidance. However, this did not have a negative impact on people due to its design and how it was discreetly positioned away from the main residential care home.

What life is like for people using this service: Since our last inspection the provider had failed to maintain consistent high quality standards of practice within the service.

Medicines were not always managed safely; quality monitoring systems had not picked up on areas of improvements required.

Outcomes for people living in the learning disability service did not fully reflect the principles and values of Registering the Right Support; people lacked choice and control over their lives and had limited inclusion in meaningful activities.

Staff raised concerns regarding low staffing levels within the residential care service at certain times of the day.

Care and support plans were not always person-centred and did not reflect people’s specific needs and future goals.

Risks to people’s health were not always assessed to provide staff with the necessary guidance on how to keep people safe.

Staff did not always follow the providers infection prevention and control procedures; they did not use personal protective equipment (PPE).

Some people's dietary needs were accurately recorded. Referrals to speech and language therapy (SALT) were made when required.

Staff received training in line with the providers policy. Some staff needed specific training to support people with learning disabilities. We have made a recommendation for this training to be provided so staff can positively support people who have a learning disability.

The service’s quality assurance process was not robust as audits failed to identify the issues we found on our visit.

Staff stated they felt supported by the registered manager. Complaints procedures were in place to address any issues raised at the service.

The service worked with other organisations and agencies to promote people’s health and wellbeing. People had access to their GP or health professionals when needed.

Rating at last inspection: Good (last report published 22 February 2018).

Why we inspected: This was a planned inspection following the opening of a new learning disability service in December 2018.

Action we told provider to take: We identified three breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014 around person-centred care, safe care and treatment and good governance. Details of action we have asked the provider to take can be found at the end of this report.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

For more details, please read the full report which is on the CQC website at www.cqc.org.uk.

This inspection took place on 19 and 20 December 2017 and was unannounced. This meant the staff and the provider did not know we would be visiting.

Windermere Grange Care Home 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

Windermere Grange Care Home accommodates 72 people in a purpose built home across two separate floors. The ground floor accommodation was for people with residential care needs (Blossom) and people with a learning disability (Coniston). The first floor was a residential unit where some of the people were living with a dementia type illness (Poppy). On the day of our inspection there were 61 people using the service.

The registered manager had left the service in September 2017. In the interim the provider had appointed the deputy manager as acting manager with support from a senior management team. At the time of our inspection there was a new manager in post who was applying to become registered with CQC. A registered manager is a person who has registered with 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.

Windermere Grange Care Home was last inspected by CQC on 18 and 21 October 2016 and was rated Requires Improvement overall and in two areas; safe and well-led. We informed the provider they were in breach of Regulation 18: staffing.

Whilst completing this visit we reviewed the action the provider had taken to address the above breach of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found that the provider had ensured improvements were made in this area and this had led the home to meeting the above regulation.

Accommodation is provided across two floors. Facilities included several lounges and dining rooms, communal bathrooms, shower rooms and toilets, hairdressing room, a large well maintained communal garden and a spacious reception area.

We saw that entry to the premises was controlled by key-pad entry and all visitors were required to sign in.

The layout of the building provided adequate space for people with walking aids or wheelchairs to mobilise safely around the home and was suitably designed for people with dementia type conditions.

The provider had procedures in place for managing the maintenance of the premises.

People who used the service and their relatives were complimentary about the standard of care at Windermere Grange Care Home. We saw staff supporting and helping to maintain people’s independence. People were encouraged to care for themselves where possible.

People were treated with respect and the staff understood how to provide care in a dignified manner and respected people’s right to privacy.

The staff knew the care and support needs of people well and took an interest in people and their relatives to provide individual personal care.

Staff had completed training in safeguarding of vulnerable adults and knew the different types of abuse and how to report concerns. Thorough investigations had been carried out in response to safeguarding incidents or allegations.

The provider had an effective recruitment and selection procedure in place and carried out relevant checks when they employed staff. There were sufficient numbers of staff on duty in order to meet the needs of people using the service.

Staff were supported to provide care to people who used the service through a range of mandatory and specialised training, supervision and appraisal.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible.

People were protected against the risks associat

We inspected Windermere Grange Care Home on 18 and 21 October 2016. This was an unannounced inspection which meant that the staff and provider did not know that we would be visiting.

At the last inspection on 29 July, 11 and 28 August 2015 we rated Windermere Grange Care Home as requires improvement. We found that the lack of effective oversight meant that for a number of months the home had ran below the staffing levels required from the provider’s own dependency tool. The process for analysing accidents and incidents needed to be improved in order to allow staff to identify trends and any preventative action that could be taken in the home. Alongside this, the audits failed to identify when care records were not accurately reflecting people’s needs; that Deprivation of Liberty Safeguard authorisations and the associated conditions were not reflected in individuals’ notes and staff were not contacting GPs to follow up changes in medication.

The registered provider sent us information to detail the actions that would be taken to make the necessary improvements.

Windermere Grange is a purpose built care home providing care for up to 72 people. The ground floor accommodates older people and since the last inspection a separate unit has been developed for people with a learning disability. The first floor accommodates older people living with dementia. All bedrooms are single occupancy with en-suite facilities and there are a number of lounge and dining areas.

The home has a manager in post who became the registered manager in September 2014. 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 and their relatives told us the staff were always very busy supporting people so had limited time with each individual. We visited from the early hours of the morning and spent time with people in each of the units. We found that the 68 people who used the service required varying levels of support. Staff worked hard to support people safely but staffing levels were not always sufficient to provide effective care. When we arrived to begin the inspection we saw staff were busy assisting people to get up and have their breakfast. Staff did not always have time to complete their support of one person before helping another. For example, we saw one person sitting in a bathroom with the door open as the member of staff helping them had been called away to assist someone else. We found that the staffing levels needed to be reviewed to ensure staff could also meet demands through the night and have time to complete all of their tasks.

At the last inspection when we reviewed the dependency tool, we found this to be extremely difficult to use and were unable to determine how staffing levels were calculated. However, the registered manager confirmed that the staffing levels had been below those set out by senior managers in the organisation. Since the last inspection the previous operational manager had reviewed the registered provider’s staffing calculation tool. A new tool had been developed but not implemented so staff remained reliant on the previous one. The new operational director told us that ensuring staffing levels consistently met people’s needs, was an area they were working on as a priority.

Staff had received Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards training and clearly understood the requirements of the Act, which meant they were working within the law to support people who may lack capacity to make their own decisions. However, staff were unclear about how to fill in the recently introduced Mental Capacity assessment forms. The registered manager had identified that staff needed additio

We spoke with four people who used the service. They told us they were treated well, the staff were nice and they felt safe at the home. One person said, “I like it here, I am happy.” Another person told us, “I am treated well, they look after me.”

We spoke with three relatives of people who used the service. One relative said, “The staff are lovely, I am involved in my mums care.” Another relative said, “I am happy with the care and have no complaints.”

We found that people were treated with dignity and respect. We saw there was a friendly and relaxed atmosphere between people living and working at the home. We observed staff interacting well with people and supporting them which had a positive impact on their wellbeing.

We saw that people who used the service had a choice of food and drink and where required people were assisted to eat and drink. We found that people had nutrition care plans and 24 hour food and drink record charts which were up to date.

We found people were cared for by staff who were supported to deliver care safely and to an appropriate standard.

We found there was an effective complaints system in place at the home.

People told us that they were not always able to make choices and decisions. They said, 'I normally get a shower once a week, in my last home it was daily, I would jump at the chance to get in daily but I can't'. Another person said, 'I am allowed a bath twice a week, you get wrong if you ask for more'.

We asked people if they felt well cared for, comments include, 'I feel a bit lost here' and 'there's not much going on, we sit in the lounge and look at each other'.

We spoke to people about the food. Comments include, 'food is pretty average, there's lots of it and you get a choice, it's the menu itself', 'food is good, there's a good choice' and 'food is terrible, don't eat much, not many like it. You don't even get nice bread for your toast on a morning'.

We spoke to people about the staff. They said, 'At times they are wonderful, at other times awful' , 'staff are very good' , 'girls are pleasant and helpful' and 'some of the girls are nice, some are not'.

We spoke to people about complaints, one person said, I could tell the manager if I had a problem'.

We inspected Windermere Grange Care Home on 29 July, 11 and 28 August 2015. This was an unannounced inspection which meant that the staff and provider did not know that we would be visiting.

At the last inspection on 13 and 24 January 2014 we found Windermere Grange Care Home was meeting requirements of five regulations reviewed.

Windermere Grange is a purpose built care home providing care for up to 73 people. The ground floor accommodates older people and the first floor accommodates older people with dementia. All bedrooms are single occupancy with en-suite facilities and there are a number of lounge and dining areas.

The home has constantly had a registered manager in post and the latest manager registered in September 2014. 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.

Albeit the provider had systems for monitoring and assessing the service, over the last year these had been reviewed and changed. We found that the lack of effective oversight meant that for a number of months the home had ran below the staffing levels required in the provider’s dependency tool. The process for analysing accidents and incidents needed to be improved in order to allow staff to identify trends and any preventative action that could be taken in a home. The tool in place only assisted staff to identify actions that could be taken for a single person rather than on. Alongside this, the audits failed to identify when care records were not accurately reflecting people’s needs; that Deprivation of Liberty Safeguard authorisations and the associated conditions were not reflected in individuals notes; and staff were not contacting GPs to follow up changes in medication.

People who used the service and their relatives found the staff worked very hard and were always busy supporting people. We visited from the early hours of the morning and spent time with people in each of the units. We found that the 61 people who used the service required varying levels of support. To some extent staffing levels reflected the different needs but the registered manager had not covered staff planned annual leave.

We found that overnight there should have been two senior care staff and four care staff. At the time of our inspection one person was on annual leave and this gap had not been covered. We found that this pattern of failing to cover annual leave had affected all departments. We found that the home staffing levels had not been in line with the provider’s expectations. Following this matter being raised on the first day of the inspection the operational director and registered manager ensured action was taken to cover shifts in line with the requirements of the provider’s staffing calculation tool.

Throughout the day the registered manager, the deputy manager, two senior care staff and seven care staff were on duty. An activities coordinator, two domestic staff, the head cook and an assistant cook were also on duty. We reviewed the dependency tool, we found this to be extremely difficult to use and were left unable to determine how staffing levels were calculated. However, the registered manager confirmed that the staffing levels had been below those set out by the provider’s senior managers.

Staff had received Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards training and clearly understood the requirements of the Act which meant they were working within the law to support people who may lack capacity to make their own decisions. We found that action was taken to ensure the requirements of the act were adopted by the staff. The provider recognised that staff needed additional support to ensure they had the skills and knowledge to consistently work with the Mental Capacity Code of Practice.

The home had a system in place for ordering, administering and obtaining medicines. However some improvements were needed in the way the staff managed medicines. Relatives told us that they had found when people’s prescriptions were changed this was not acted upon by staff. We looked at the care file for one person who was reported not to have received appropriate pain relief and saw that staff had not collected the person’s prescription in a timely manner. We reported this matter to the local safeguarding team.

We found that staff as custom and practice left people’s bedroom doors open whilst people were asleep in their rooms. Staff could provide no explanation for this practice and we saw it compromised people’s dignity.

People we spoke with told us they felt safe in the home and the staff made sure they were kept safe. We saw there were systems and processes in place to protect people from the risk of harm. Safeguarding alerts were appropriately sent to the local authority safeguarding team and fully investigated.

People’s needs were assessed and care and support was planned and delivered in line with their individual care needs. The care plans contained comprehensive and detailed information about how each person should be supported. We found that risk assessments were detailed. They contained person specific actions to reduce or prevent the highlighted risk.

People were supported to maintain good health and had access to healthcare professionals and services. People were supported and encouraged to have regular health checks and were accompanied by staff or relatives to hospital appointments.

People told us they were offered plenty to eat and assisted to select healthy food and drinks which helped to ensure that their nutritional needs were met. We saw that individual’s preference were catered for and people were supported to manage their weight and nutritional needs. We found that the provider was in the process of reviewing the catering budget and menu, as they had found these could be improved.

The interactions between people and staff were jovial and supportive. Staff were kind and respectful; we saw that they were aware of how to respect people’s privacy and dignity.

People were complementary about the staff and found that home met their needs. People told us that they felt the staff had their best interests at heart and if they ever had a problem staff helped them to sort this out.

We saw that the provider had a system in place for dealing with people’s concerns and complaints. The registered manager ensured that concerns were thoroughly investigated. People we spoke with told us that they knew how to complain. People who used the service and staff were extremely complimentary about the support the registered manager provided and told us that they were always accessible and available to discuss any issues at the home.

Effective recruitment and selection procedures were in place and we saw that appropriate checks had been undertaken before staff began work. The checks included obtaining references from previous employers to show staff employed were safe to work with vulnerable people.

Staff had received a wide range of training, which covered mandatory courses such as fire safety as well as condition specific training such as Dementia and Diabetes. We found that the provider not only ensured staff received refresher training on all training on an annual basis but routinely checked that staff understood how to put this training into practice.

Regular surveys, resident and relative meetings were held and we found that the information from these interactions were used to inform developments in the home such as the change in menus.

Checks of the building and maintenance systems were undertaken..

We found the provider was breaching two of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This related to the governance arrangements. You can see what action we took at the back of the full version of this report.