What life is like for people using this service:

Since the previous inspection the registered provider has worked to address the issues identified to ensure a more person centred, effective and safe service for people living at Winsford Grange.

The current registered manager has been in post since October 2018 and is supported by an interim manager, clinical lead, area manager and the registered provider's quality team. Since their recruitment into the role the registered manager has made numerous improvements to the service. These improvements remain on-going.

The new leadership of the service now promoted a positive culture that was person centred and inclusive. People and family members commented on the previous concerns about the service but were aware of the current improvements being made. Staff described the registered manager as supportive and approachable. The management team showed a continued desire to improve on the service and worked closely with other agencies and healthcare professionals in order to do this. Effective systems were now in place to check on the quality and safety of the service and improvements were made when required.

Whilst improvements had been made, we identified a continued breach of regulation in relation to records and safe care and treatment.

People told us they felt safe living at Winsford Grange. In the majority of cases risks that people faced were identified through assessments and measures put in place to manage them and minimise the risk of harm occurring. However not all risks assessments had been fully completed and some potential risks had not been assessed and planned for. The registered manager was in the process of updating care records and assessments to accurately reflect people’s needs.

Most aspects of the environment were safe however some environmental safety issues were identified that could place people at risk of avoidable harm. These issues were in the process of being addressed by the registered manager. People had access to appropriate equipment where needed. Staff showed a good understanding of their roles and responsibilities for keeping people safe from harm. Medicines were managed safely and people received their prescribed medicines at the right time.

The recent recruitment of permanent staff and the closure of one of the units within the service had helped to ensure that sufficient numbers of suitably qualified and skilled staff were deployed to meet people’s individual needs. The service had previously relied heavily on the use of agency staff to cover shortfalls in staffing numbers, however this had since reduced. Staff received a range training and support appropriate to their role and people's needs.

Staff showed genuine motivation to deliver care in a person-centred way based on people’s preferences and likes. People were treated with kindness, compassion and respect. Staff used techniques to help relax people with positive outcomes. Staff had developed positive relationships with people and some family members and were seen to display kind and compassionate support to people.

People’s needs and choices had not always been assessed and planned for; some care records lacked detail in relation to some aspects of people’s care and support needs. Most care plans identified intended outcomes for people and how they were to be met in a way they preferred. People told us they received all the right care and support from staff who were well trained and competent at what they did. People received the right care and support to maintain good nutrition and hydration and their healthcare needs were understood and met. People who were able consented to their care and support. Where people lacked capacity to make their own decisions they were made in their best interest in line with the Mental Capacity Act.

People received personalised care and support which was in line with their care plan. However, some care plans lacked detail in relation to people’s

The inspection took place over three days on the 23, 24 and 25 May 2018, the first day was unannounced and the other two days were announced.

At the last inspection on the 24 and 25 March 2015 the service was rated as good. We did however ask the provider to take action to make improvements in relation to capacity and consent. We found at this inspection that the required improvements had been made.

During this inspection we found multiple beaches of the Regulations in regards to safe care and treatment, personalised care, dignity and respect, record keeping and good governance.

Winsford Grange Care Home 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.

Winsford Grange accommodates up to 60 people in one building across three separate units, each of which have separate adapted facilities. At the time of the inspection 57 people were living at the service.

The service has 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.

Management of medicines was not safe. Medication was not checked to ensure that it was in date and stored correctly. Adequate information was not available to staff to ensure that medication was correctly administered.

Where risks to health and welfare were identified, robust risk assessment and management plan were not always in place to assist staff in minimising the risk of future harm. Equipment used to manage the risk of developing pressure ulcers was not checked to ensure it was set correctly.

Care plans were in place which aimed to assist staff in providing the correct level of care and support to a person. These however were not accurate or up-to-date. This meant that there was a risk that staff less familiar with the person may not provide the right level of care treatment. Other records, used to evidence care provided were incomplete. Therefore, we could not ascertain whether people had received care and support to meet their needs.

People who used the service and their relatives described it as being "unsafe" due to their concerns about staffing levels. People did not receive their care in line with the needs and wishes. At other times, a person's dignity or respect was compromised due to interventions or lack of response by staff. The register provider could not demonstrate that staffing levels were sufficient to meet people’s needs.

There was a lack of stimulation and social engagement for people throughout the day. People and relatives commented that there were long periods of the day with nothing to do. We made a recommendation that the registered provider undertake a review of activities to reflect the needs of people at the service and best practice guidelines.

The systems in place to monitor the quality and safety of the service were ineffective. Where issues had been identified action had not been taken by the register provider to make positive changes in a timely manner. Audits undertaken by the registered provider failed to highlight a number of concerns which we found at this inspection.

People received meals that were nutritionally balanced. However, people felt that there was a lack of choice in regards to their meals. We observed that some people went a long period without food or drink. Staff did not keep accurate records detailing what a person ate or drank throughout the day which meant there was no guarantee that people had been provided with the food and drink they needed to keep them healthy and well.

Staff had an awareness of the Mental Capacity Act

We spoke to four people who used the service who said they were getting the support they needed. Some comments made were: -

“The staff are very caring. When I was ill one night, they were with me all night.”

“I am getting the help I need.”

“The staff are lovely. I enjoy the food. If I need help I don’t have to wait long.”

We spoke to five relatives who described the staff as supportive and caring. Some comments made were: -

“The staff are lovely. They are very kind.”

“The staff know my relative and she knows them. She’s very settled. Staff always speak pleasantly to her.”

We observed that staff were respectful and caring towards the people who used the service.

The expert by experience considered that the home was well managed and that the people who used the service and relatives were very happy with the care and support provided and with the standards of the home environment.

We found that people had been assessed before they began to use the service and they had care plans that identified their needs and how they were to be met.

The home was clean with good systems in place to promote infection control.

The staff were provided with the support they needed to enable them to meet the needs of the people who used the service.

There were systems in place to monitor the quality of the service which meant that any shortfalls could be identified and improvements made when necessary.

We spoke to three people who used the service. They said they were well looked after and happy with the service received. They were positive about the staff who supported them.

We spoke to three relatives who told us that they were happy with the care and support provided. They said they were kept informed about their relatives’ well-being. They described the staff as professional, caring and attentive.

We spoke to one professional who had made placements at the service. They said that a good service was provided at the home.

There were practices in place to ensure that the people who used the service were respected and that they were involved in the delivery of the service they received as far as this was possible.

Records showed that people had been assessed before they began to use the service and they had a care plan in place enabling staff to identify and address their needs.

The staff were provided with the training and support they needed to enable them to meet the needs of the people who used the service.

We found that there were good systems in place to monitor the quality of the service. Where issues had been identified action was taken to address any shortfalls.

The inspection took place on the 24th and 25th of March 2015. The provider did not know we were visiting for the first day but was aware that we were visiting on the second day. Winsford Grange is a purpose built care home registered to provide nursing care and accommodation for up to sixty older people. Care is provided over four units; two of which are for older people with nursing needs and the other two providing nursing care for people living with dementia. The service is set in its own grounds just outside the town centre of Winsford in Cheshire. It is close to local amenities. Nursing, care and ancillary staff are on duty twenty-four hours a day to provide support. At the time of our visit there were fifty-five people living there. The service has a registered manager who has been in post for a number of years. 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 registered manager was not present for our visit as we had been advised that they were absent from the service at the time. The deputy manager was available during both days of our visit and was able to assist fully with the inspection. The deputy manager had been asked to take over the management of the service in the registered managers’ absence given her experience of working in the service for many years. People who were able to told us that they were happy living at Winsford Grange and felt safe living there. This view was echoed by relatives. They told us that staff were very good at their jobs and had all their needs met. They told us that staff cared about them and that their health remained good thanks to the care and attention they received. People lived in an environment that was clean, hygienic, well maintained and designed to enable them to move independently. People received care that was personalised and met their needs effectively. People had care plans which were person centred. This included an acknowledgement of their health needs but also placed emphasis on their social history and interests. We saw that care practice matched the information included within care plans.

We found that the provider had not thoroughly assessed the capacity of individuals. The conclusion made by the provider that people lacked capacity had not included all people involved in the people’s care. There was no evidence that the best interests of people had been fully discussed. This is a breach of R

egulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.