We carried out a comprehensive inspection of Bedale Grange Care Home on 16, 17, 22 and 25 October 2018. The first day of the inspection was unannounced. At our last inspection in September 2017 we rated the service requires improvement. This was because improvements were required to ensure all environmental risks were identified and the provider's quality monitoring systems were effective in monitoring and improving the quality and safety of the service. At this inspection, we found the service had improved and we rated it good overall.

The service is a ‘care home’. People in care homes receive accommodation and nursing or personal care as 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.

Bedale Grange Care Home provides nursing and personal care in one adapted building for up to 20 older people, some of whom are living with dementia. The property has been refurbished and is set over two floors. The first floor is accessed either by stairs or a passenger lift. At the time of this inspection 13 people were living at the service.

There was a registered manager in post. A registered manager is a person who has registered with the 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.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions of safe and well-led to at least good. At this inspection, the provider had improved their systems to ensure any environmental risks were identified. The provider had also improved their quality assurance processes to ensure they were effective in monitoring and improving the quality and safety of the service.

There were systems and processes in place to protect people from the risk of harm. Risk assessments had been completed to reduce the risk of harm Accidents and incidents were analysed to reduce the risk of reoccurrence. Staff understood the signs people may be being abused and how to respond to keep people safe.

Staffing levels were sufficient to meet people's needs. There were safe recruitment and selection procedures in place and appropriate checks had been undertaken before staff began work. Staff received the support and training they needed to give them the necessary skills and knowledge to meet people's assessed needs. The registered manager made sure people were involved and received effective care that met their needs and wishes. People were protected from discrimination and harassment.

People received food and drink of their choice. Staff responded quickly to people's changing needs and appropriate action was taken to ensure people's wellbeing was protected.

People received care in line with the Mental Capacity Act 2005 and received choice in relation to their care. 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.

Person-centred care was provided by kind and caring staff who promoted people's independence. People were supported to maintain contact with family and friends and take an active part in recreational and leisure activities.

There were regular opportunities for people, relatives and staff to give their feedback on the service and the registered manager and provider had systems in place to monitor the quality of people's care and make improvements.

We inspected Bedale Grange Nursing Home on 13 and 18 September 2017. The first day was unannounced and we told the provider we would be visiting on the second day.

Bedale Grange Nursing Home provides nursing and personal care for up to 20 older people, some of whom are living with dementia. The property is set over two floors and the first floor is accessed either by stairs or a passenger lift. At the time of this inspection 12 people were living at the service, ten permanently and two receiving a temporary respite service.

The provider is required to ensure a registered manager is in post as part of their registration. A manager was new in post and they had commenced the process to register. 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 the last inspection on 10 and 15 September 2015 the service was rated good. We asked the provider to take action to make improvements to assess and monitor the quality and safety of the service.

At this inspection we found the service required improvement. Quality assurance and governance processes were not yet fully established or sufficiently robust to ensure the safety and quality of the service. While staff received verbal handovers at the start of their shifts, there were some gaps in care records, which meant staff did not always have up to date written information to ensure they met people's needs effectively. In addition to their management role the manager also worked in the home as a nurse to support continuity of care within the care home. This did impact on the time available to them to focus on making improvements.

People were placed at potential risk of harm because the provider had not taken action to identify and minimise certain environmental health and safety risks. For example, on the first day of inspection we observed one person had their call bell out of reach, which meant that they could not call for assistance. Hazardous substances that required secure storage were seen in unlocked areas, which could be accessed by vulnerable people. The manager did take action when shortfalls were raised with them. However, we felt these issues should have been picked up earlier through the provider’s own audit and management systems, to ensure people's health and safety was protected at all times.

We have found one breach of regulation during this inspection in relation to the governance of the service. You can see what action we told the provider to take at the back of the full version of the report.

We saw safe recruitment and selection procedures were in place and appropriate checks had been undertaken before staff began work.

The management of medicines was safe and people received their medications as planned.

Individual care plans and risk assessments reflected people’s needs and staff knew people well. People and relatives told us they were happy with the care provided and we saw staff treated people with dignity and respect. 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 support this practice.

People said they had a good choice of food and enjoyed their meals. Their weights were monitored and we saw professionals were contacted for advice if staff had any concerns.

A good range of recreational activities were organised and we saw these being provided and really enjoyed by most people. It was clear that individual independence and choice was encouraged.

People told us they were confident to raise any concerns and felt that the new manager was very approachable.

Appropriate maintenance checks of the building and maintenance systems were undertaken t

One inspector carried out this inspection. At the time of our inspection 10 people were using the service. Below is a summary of what we found.

We spent time speaking with people who lived at Bedale Grange Care Home as well as speaking with staff and relatives. We reviewed records and spent time observing people in the home. If you want to see the evidence that supports our summary please read the full report. We used the evidence to answer five questions.

Is the service safe?

People were cared for in an environment that was safe, clean and hygienic. Equipment at the home had been well maintained and serviced regularly. There were enough staff on duty to meet the needs of the people who lived there. We spent time observing people and noticed that they were cared for safely. Every member of staff we spoke with said that they were happy with staffing levels and said that these helped to provide safe and appropriate care.

Staff records demonstrated that mandatory training was up to date and that staff were trained to meet the complex needs of people. Staff were trained in the use of the Mental Capacity Act 2005, moving and handling and hygiene and infection control.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications had needed to be submitted, 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.

Is the service effective?

During our visit we spent time with people and staff. It was clear from our observations and from speaking with staff that they had a good understanding of people's care and support needs and that they knew them well. For example, we noted that staff were able to tailor the way they spoke to each person, particularly their volume and tone of speech, to be able to make each person feel listened to and important.

People were cared for by staff who were supported to deliver care safely and to an appropriate standard. Staff had received training to meet the needs of the people living at the home and told us that they were able to put their training into practice.

Is the service caring?

People were supported by kind and attentive staff. We saw that staff showed patience and gave encouragement when supporting people. Staff told us that they worked hard to make sure their training was applied to the individual needs of people so that they could be supported appropriately.

Staff said that they were happy with the level of professional and emotional support they received from the registered manager.

Is the service responsive?

People's needs had been assessed before they moved into the home and these were checked by regular reviews, in which they were involved. People's needs assessments included an assessment of their capacity to make decisions as well as consideration of their dietary and nutrition requirements.

Some people were not able to understand their care needs or their care and treatment options. In such cases staff had used medical advice and multi-disciplinary best interests assessments to make sure that people's care and treatment was appropriate and responsive to any changes in a person's needs.

Is the service well led?

Staff had a good understanding of the ethos of the home and quality assurance processes were in place. Staff told us that they were clear about their roles and responsibilities and that management support helped them to do their job effectively. One person spent time talking with us and said, "The staff are all lovely. They make time for you and I trust them very much."

People were supported to make decisions and choices regarding their care and treatment. They told us that they were treated with dignity and respect. One person said " I can do as I please, the staff help me but I can make my own mind up to what I want".

People told us they were well cared for and liked living at the home. One person said “If I need the doctor the staff sort it out for me, and the doctor comes here".

We looked at how people’s medication was administered at the home. We found policies and procedures in place that staff were following to ensure that people got their prescribed medication safely and properly.

When we looked at staff files we saw that proper recruitment procedures had been followed and checks were made on staff to make sure they were safe to work with vulnerable people.

The service has measures in place to audit people’s satisfaction of the service they are receiving. We saw comments such as "Staff are very attentive and caring". As well as satisfaction surveys the manager audits other areas of the home such as care records, accidents that occur in the home, medication and complaints. This means that the provider had an effective system to regularly assess and monitor the quality of service that people receive.

During our visit we spoke with some people who lived at the home. They told us that they were very happy with the care and support they were receiving. One person said 'It's a lovely place to be, the staff are great and can always cheer me up when I feel down.'

People had support plans and risk assessments in place which helped staff to understand and meet people's needs. We saw staff helped people to maintain their independence and make choices for themselves. One person said ‘All I want is a to sit and watch my television and have my meals served to me. That’s what I got at home and that's what I get here.'

A visitor at the home told us that they were very happy with the care their relative was receiving, another said that the staff were 'Very special, kind people.'

People said they were happy at Bedale Grange. One person said "It's alright, very nice" and another said "It's alright here." People told us that they were happy with the care they were receiving.

People said they felt safe at Bedale Grange. They also said they were happy with the staff and the care that they provided. One person told us that "The staff are very good, all of them." We also spoke with peoples relatives who were visiting and they gave positive feedback on the staff.

People told us they were happy with the service and knew how to raise issues, should they have any. They also said that the manager is prepared to see people at any time.

This inspection took place on 10 & 15 September 2015 and was unannounced.

Bedale Grange Care Home is registered to provide nursing and personal care for up to 20 older people. The service is situated in the market town of Bedale, located in a quiet residential area. The property is set over two floors and the first floor is accessed either by stairs or a stair lift, there is no passenger lift available. At the time of this inspection eleven people were living at the service, ten permanently and one receiving a temporary respite service.

The service had a registered manager, who had been registered with us since October 2010. 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. On the first day of our inspection the registered manager was on holiday, but the deputy manager was on duty. The registered manager was on duty for the second day of our inspection.

People using the service, and their relatives, told us they felt safe at Bedale Grange. People had individual risk assessments in place which ensured staff were aware of the risks relevant to each person’s care.

Staff knew how to report any concerns about people’s safety or welfare and had confidence in the registered manager taking appropriate action.

Overall the service’s premises and equipment were maintained in safe working order. We identified a potential safety issue with window restrictors during our visit, but we raised this with the registered provider and it was rectified during our inspection.

Staff were recruited safely and there were enough staff to provide the care people needed.

Medicines were safely managed and administered. However, we found that some improvements could be made to the records relating to medicines, to ensure that detailed information about the management of people’s medicine and a full audit trail was available.

Staff were supported to have the skills and knowledge they needed through relevant training, although induction records for a new member of staff were not available when we asked to see them. Regular staff appraisals had taken place and a new system for regular supervision was about to be implemented.

The service was following the principles of the Mental Capacity Act 2005. At the time of the inspection no-one was subject to a DoLS authorisation, but the registered manager understood the Deprivation of Liberty safeguards (DoLS) and when they were needed.

People told us that the food was generally very good, with plenty of snacks and drinks available between meals if people wanted them. People’s dietary needs were assessed and monitored, with support requested from relevant health care professionals where there were concerns about people’s nutritional wellbeing.

We received positive feedback from health care professionals who told us the service worked well with them and provided a good standard of care to people.

People told us that they were well cared for and usually treated with dignity and respect. However, we received some negative feedback relating to the attitude of one member of staff and how this had made people feel uncomfortable. This was raised with the registered manager at the time of our inspection so that they could take action.

People had their needs assessed and had care plans which were individual to them. Care and nursing staff knew people well and were able to describe people’s needs.

People had access to activities and were involved in their local community, with an activities coordinator working in the service two or three days each week. However, people felt that social stimulation and activities were sometimes lacking when the activities coordinator was not on duty.

A complaints procedure was in place and displayed in the reception area. The registered manager encouraged feedback from people who used the service and their relatives, inviting people to come and speak with them whenever they needed to. They had also recently sent surveys to the relatives of people who used the service asking for feedback. Feedback was taken seriously and acted on promptly.

The service had a long standing and experienced registered manager, who was open and honest throughout the inspection. There was a strong staff team, with many staff who had worked at the service for a long time. Staff were committed to providing good care and felt well supported by the registered manager.

The service was allocated two and a half designated management days a week. Management staff felt they struggled to implement full management systems in the time available.

We found that governance systems could be improved and were not always effective. For example, formal audit systems had not been fully implemented, and some aspects of maintenance and record keeping could be improved. Some of the management information provided to us during the inspection visit was not the most up to date version available.

We identified a breach of regulation. You can see what action we told the provider to take at the back of the full version of the report.