This was an unannounced inspection which took place on the 21 March 2017. The service was last inspected in May 2016 and a requirement notice was issued as the service had not always kept people safe. Improvements had been made since our last inspection to keep people safe and ensure staff responded consistently to emergencies.

Appletree Grange is a 32 bed care home that provides personal care to older people and people with a dementia related condition. Nursing care is not provided. There were 32 people living there at time of inspection.

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 home was warm, clean and had comfortable communal areas inside and outside. People, relatives and staff told us the bedrooms and internal communal areas were small. There were sufficient numbers of staff, with the required skills to meet the needs of the people living there.

People or their relatives told us they felt safe, and were being cared for by staff who knew them as individuals. Staff told us they knew how to raise concerns and had confidence action would be taken if they had any issues. Relatives told us they felt their families were safe at Appletree Grange and the home was always welcoming and had a homely atmosphere.

Risks to people, such as from malnutrition and skin integrity issues, were assessed and care plans were in place to protect people from harm. Where people’s needs changed, referrals were made for health care services and any advice from professionals was integrated into people’s care plans.

Staff were trained and managed so that they could work flexibly with different people and were deployed so that at peak times there was sufficient staffing in place. Staff were flexible throughout the day to meet the needs of people, for example ensuring support for people at mealtimes.

People’s medicines were managed safely; stock control and ordering were managed by trained staff with checks of staff competency to ensure that the risk of errors were minimised. Audits were carried out regularly to ensure that any errors would be quickly identified.

Care was effective and people received care based on best practice and the advice of external professionals. Care plans were detailed and personalised. People’s consent to receive care was sought, where this was possible. Where people could not consent, their care was delivered in their best interests after consultation with relevant people and professionals.

There were a number of people subject to Deprivation of Liberty Safeguards (DoLS) and these had been managed well by the service with referrals for local authority authorisation being made appropriately. The service had a system in place to ensure that renewals were requested promptly.

Staff were recruited robustly and received training based on the needs of people using the service including dementia awareness. Staff had undergone an induction period and their mandatory training was up to date.

People were supported to eat and drink and maintain a healthy diet. Staff supported people at mealtimes in a dignified way. The service monitored people’s weights and took further action if needed. Visiting health care professionals told us the care and support offered was effective.

Care interactions observed were positive and there were good relationships between people and staff. All the staff we spoke with knew people’s needs well and spoke about them in a positive way. People and their families were encouraged to express their views and to be involved in making decisions about their care and support. There was evidence of people’s involvement in their pre-admission assessments and reviews of car

This was an unannounced inspection which took place over two days, the 4 and 9 May 2016. The service was last inspected in July 2014 and was meeting the regulations in force at the time.

Appletree Grange is a 32 bed care home that provides personal care to older people and people with dementia. Nursing care is not provided. 32 people were living there at time of inspection.

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 home was warm, clean and had comfortable communal areas, the bedrooms and communal areas were small. There were sufficient staff, with different skills to meet the needs of the people living there.

One family told us they felt the service had not kept their relative safe as staff failed to intervene when required. We found that staff had lacked the confidence and competency to support the person and that the normal procedures had not been followed by staff. Action had been taken by the provider following this incident.

Other people or their relatives told us they felt safe, and were being cared for by staff who knew them well. Staff told us they knew how to raise concerns and had confidence action would be taken if they had any issues. Relatives told us they felt their families were safe at Appletree Grange and the home was welcoming and had a happy atmosphere.

Risks to people, such as malnutrition and skin integrity, were assessed and care plans were in place to protect people from harm. Where people’s needs changed, referrals were made for health care services and any advice from professionals was integrated quickly into the care plans and acted upon.

Staff were trained so that they could work flexibly with different people and were deployed so that at peak times there was sufficient staffing. Staff were effectively deployed throughout the day to meet the needs of people. For example ensuring support for people at mealtimes.

People’s medicines were managed safely; stock control and ordering were managed by trained staff with checks to ensure that the risk of errors were minimised. Audits were carried out regularly to ensure that staff were competent and that any errors would be quickly identified.

Care was effective and people received care based on best practice and the advice of external professionals. Care plans were detailed and personalised. People’s consent to receive care was sought, where this was possible. Where people could not consent, their care was delivered in their best interests after consultation with family and professionals.

There were a number of people subject to Deprivation of Liberty Safeguards (DoLS) and these had been managed well by the service with referrals for local authority authorisation being made appropriately. The service had a system in place to ensure that renewals were requested promptly.

Staff were recruited robustly and received training based on the needs of people using the service including dementia awareness. Staff had undergone an induction period and their mandatory training was up to date.

People were supported to eat and drink and maintain a balanced diet. Staff supported people at mealtimes in a dignified way. The service monitored people’s weights and took further action if needed. Visiting health care professionals told us the care and support offered was effective.

Care interactions observed were positive and there were good relationships between people and staff. All the staff we spoke with knew people’s needs well and spoke about them in a positive manner. People and their families were encouraged to express their views and were encouraged to be involved in making decisions about their care and support. There was

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2012, and to pilot a new inspection process being introduced by CQC which looks at the overall quality of the service.

This was an unannounced inspection carried out on 29 July 2014. At the last inspection on 20 June 2013, we asked the provider to make improvements in the management of medicines. We visited the service in October 2013 to confirm this action had been complete. 

Appletree Grange provides person care for up to 32 older people and people living with dementia. At the time of our inspection there were 30 people living at the service.  

A registered manager was in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

People told us they felt safe living at Appletree Grange. All staff had received training in safeguarding vulnerable adults. The staff members we spoke to were knowledgeable about the safeguarding procedures and could talk us through the process they would follow if they had any concerns.

The registered manager and senior staff were knowledgeable about the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). We saw that where required the registered manager had submitted applications for DoLS.

We looked at four staff member’s recruitment files and noted all appropriate checks were complete prior to them starting work. Staff told us they received sufficient training for their role and they regularly received supervision and had an appraisal with their line manager on a yearly basis.

During our inspection we spoke to the cook who was knowledgeable about people’s individual dietary needs. The cook explained how all things were cooked fresh, including cakes and scones. We saw, where required, people were assisted during meal times by staff members.

Everyone we spoke to gave us positive feedback in relation to the care and support they received at Appletree Grange. We observed all staff members had good interactions with the people who lived at the service. Relatives told us they felt staff helped promote people’s privacy and dignity.

We noted the service employed an activities coordinator and a wide variety of activities were available to people on a daily basis, both in and out of the service. Relatives told us staff were responsive and mindful of people’s needs.

People told us they were aware on how to raise a complaint. We looked at the complaints log and noted no complaint had been raised in the last 12 months.

Staff told us the manager was approachable. We spoke to staff about their roles and responsibilities and they were clear as to the management structure as well as their individual responsibilities or who they would go to for support.

We saw the provider conducted an inspection on a monthly basis to look at the quality of the service provided. The registered manager told us an action plan was produced for any areas of development. The senior care workers told us about other audits that were complete on a regular basis such as medication and health and safety.  

At our previous inspection we had found concerns with the home's arrangements for medicines. We carried out this inspection to check whether action had been taken to address these concerns. We found there were improved arrangements to make sure people living at the home were given their prescribed medication safely.

People living at the home, and their representatives, were consulted about, and agreed to their care and treatment.

We found that care was planned to meet individuals assessed needs and manage risks to their personal safety. But arrangements for medication were not robust enough to ensure people were always given their medication safely.

A range of checks were carried out when new staff were recruited to make sure they were suitable to work with vulnerable people.

There was an appropriate procedure for making complaints. People and their visitors spoke highly of the service and told us they had no concerns.

We carried out this inspection in response to information we had received. This alleged that, at times, there was only two staff at night to care for people living at the home.

We visited the home late evening and saw that there was three care staff, including a senior care worker, on night duty. Each of the staff we spoke with told us this was the usual number, and staff rotas confirmed there had been no reduction. Cover for absences was also organised to prevent any shortfalls to the staffing levels. We found there were appropriate arrangements to ensure there was enough staff to meet the needs of people living at the home.

People living in the home and relatives told us they were consulted and felt involved in decisions about their care. Their comments included: “I’ve attended reviews of my mother’s care”, and, "The staff know the help I need and what I can do for myself". Individual’s preferences were built into their planned care and staff showed they understood the ways that people wished to be supported. Social needs were well catered for through a varied programme of activities and events that promoted people’s involvement in the community.

All reasonable steps were taken to prevent people living in the home from being harmed. Staff were trained to safeguard vulnerable people and knew how to report any suspected abuse or poor care practice. People said they felt secure living in the home and we saw that risks to their personal safety were identified and managed.

Since our last inspection improved staffing levels had been maintained to make sure people’s needs were met, and all staff were being provided with regular supervision and appraisal of their work.

We found that people’s views, and those of their representatives, were taken into account to monitor and improve the quality of the service. People spoke positively about the care and support they received and told us they were satisfied with the service. Their comments included: “The home came recommended and has lived up to its’ reputation” and “My mother receives a good standard of care”.

People living in the home and their visiting relatives told us they were happy and content in the home and felt well cared for. They said that staff responded to calls for attention, although they sometimes had to wait up to ten minutes, as staff were always busy. They said they were treated with respect and spoke highly of the friendliness and commitment of the staff team.

Staff told us they worked hard to provide a good quality of care for the people in the home, but felt they did not have enough time to meet individual needs promptly. In particular, those persons who required assistance from two members of staff would often have to wait longer for attention, until enough staff were available to address their needs. They also told us they did not always have enough time to read or refer to people’s individual care plans.

Our observations during this inspection confirmed what we were told by residents, staff and visitors. Residents in communal areas and in their own rooms were not adequately supervised, nor given sufficient social stimulation, despite the staff’s best endeavours to meet everyone’s needs.

We shared our concerns with a representative of the company, who accepted our findings and provided extra staffing resources within 24 hours of this inspection. The company told us an extra care worker had been added to the home’s early and late shifts every day.