This inspection took place on 24 and 30 January 2018. The first day of the inspection was unannounced.

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

Berwick Grange offers both residential and nursing care for up to 52 older people and people living with dementia. Accommodation is provided over three floors, each of which has separate communal facilities. Residential care is provided on the ground floor and nursing care is provided on the upper floors. At the time of our inspection there were 52 people living at Berwick Grange, 32 of whom required nursing care.

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. The registered manager was available and assisted on both days of the inspection.

At the last inspection on 22 December 2015, the home was rated Good. At this inspection we found standards had not been maintained and required improvement. This is the first time the service has been rated Requires Improvement.

We found breaches of Regulation 12 (safe care and treatment) and Regulation 17 (good governance) of the Health and Social care Act 2008 (Regulated Activities) 2014.

Staff were not consistently following the provider's medicine policy and this meant people were at risk of not receiving their medicines safely. For example, medicines that required cold storage were not always stored at the correct temperature. Arrangements were not in place to ensure people’s topical medicines such as creams and ointments were well managed. There was limited specific written guidance for the use of ‘as required’ medicines to enable staff to provide a consistent approach to the administration of this type of medicine.

Risks to people were identified and assessed but care plans to reduce those risks and guide staff on how to manage specific risks were not always established. This meant people were at risk of receiving unsafe or inconsistent care.

Management systems were not always effective in identifying shortfalls in the quality of the service. Some records were not complete or well maintained and staff training was not fully embedded or supported by effective supervision and support. This had led to inconsistency in some areas of practice across the home.

Staff were recruited safely. Whilst there were enough staff on duty to care for people safely, the availability of staff sometimes impacted people’s care. This was identified as an area that needed to improve.

Staff had received training but our observations were that staff did not always apply their learning in practice. We saw staff who were confident, polite, well-mannered and accommodating however we also saw examples of inappropriate staff responses. We have made a recommendation about staff training on the subject of dementia.

People received a varied diet. However our observations were that some people did not always receive the consistent help they needed to eat their food. This was identified as an area of practice that needed to improve.

Arrangements were in place to maintain the cleanliness of the home but these were not always effective in practice. We found some areas, which required updating. We made a recommendation that the provider seeks further information about best practice in the use of colour and design within the environment to help people with dementia to orientate themselves in time and place. Environmental risks were assessed and monitored and the home and equipment were well maintained.

While we foun

The inspection took place on 22 December 2015 and was unannounced. We carried out an inspection in September 2014, where we found the provider was meeting all the regulations we inspected.

Berwick Grange is a 52 bedded purpose built home run by Methodist Homes in Harrogate. The service is for people living with dementia, and offers both residential and nursing care. It is situated on the main road running in to Harrogate, and is fully accessible to people with mobility needs. Every room has an en-suite bathroom, and there are various communal and secure outside areas that can be accessed easily.

At the time of the inspection, the service had a manager registered with the Care Quality Commission (CQC). 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.

We found the premises complied with current Health and Safety guidance and were therefore safe for people who used the service, visitors and staff.

We found people were cared for, or supported by, sufficient numbers of suitably qualified and experienced staff. Robust recruitment procedures were in place to make sure staff were suitable to work with people who used the service. Staff completed an induction when they started work. Staff received the training and support required to meet people’s needs.

People told us they felt safe in the home and we saw there were systems and processes in place to protect people from the risk of harm. Staff had a good understanding of safeguarding vulnerable adults and knew what to do to keep people safe. People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines safely.

The care plans we looked at contained appropriate mental capacity assessments. At the time of our inspection ten Deprivation of Liberty Safeguard applications had been applied for and two had been applied for and approved. There were opportunities for people to be involved in a range of activities within the home or in the wider community.

People’s care plans contained sufficient and relevant information to provide consistent care and support. People’s mealtime experiences were good. People received good support which ensured their health care needs were met. Staff were aware and knew how to respect people’s privacy and dignity.

The service had good management and leadership in place. People had the opportunity to comment on the quality of the service and influence service delivery. Effective systems were in place which ensured people received safe care which was of a good quality. Complaints were welcomed and if received were investigated and responded to appropriately.

Our inspection team was made up of a lead inspector. During the inspection we asked five questions; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

On the day of the inspection we met people living in the service. People living at Berwick Grange had dementia type illnesses which made it difficult to communicate. During the day we spent time observing interactions with people and staff in three different communal areas in the home. We talked with three people about their experience of care and we spoke with the relatives of three people. We talked with eight staff and looked at records. We spoke with a visiting general practitioner (GP). Below is a summary of what we found.

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

Is the service safe?

People were treated with respect and dignity by the staff. Relatives we spoke with told us that they believed their relatives were safe and well cared for. Staff had received training in safeguarding and understood how to safeguard the people they supported. Systems were in place to make sure that managers and staff learnt from events such as accidents and incidents. This reduced the risk to people and helped the service to continually improve.

People were cared for in a service that was safe, clean and hygienic. Risk assessments were in place in individual care plans in relation to all activities of daily living. Training records demonstrated that the staff employed to work in the home had completed required training and were supported to develop skills and experience needed to provide care for people living at Berwick Grange. Staffing levels were appropriate to meet the needs of the service and were reviewed and adjusted to address any changing needs.

Is the service effective?

People told us that they were happy with the care they received. One person said, "I like it here, they're all nice here." Relatives told us that they believed the needs of their relatives were being met. One relative told us, "It's an amazing home, it's like a big family really." It was clear from what we saw and from speaking with staff that they understood people's individual care and support needs and they knew them well. People's health and care needs were assessed with them where this was possible and family members were also involved in discussion about their plans of care. Staff spoke with pride about the progress that individual people had made whilst they had been living in the service. Relatives we spoke with were able to describe specific benefits to the health and wellbeing of their relatives. One person told us, "They've been absolutely amazing, everybody's worked really hard."

Is the service caring?

People were supported by kind and attentive staff. We saw that staff were patient and gave encouragement when supporting people. We observed that people were supported to do things at their own pace and to be as independent as possible. People who used the service and their relatives were invited to complete an annual survey. Where shortfalls or concerns were raised, these were addressed. People's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with their wishes. One member of staff told us, "I think we do a good job here, we work closely with families and we're open to finding out what people liked to do."

Is the service responsive?

People were regularly involved in a range of activities within the home and also occasional trips out. The home supported people to take part in activities and employed the services of a music therapist. People knew how to make a complaint if they were unhappy and two people we spoke with told us that they felt that they could talk with any of the staff if they had a concern or were worried about anything. We saw from care plans that the staff responded to changes in the support needs that people had. One staff member told us, "We assess people on so much of an individual basis."

Is the service well-led?

The service worked well with other agencies and services to ensure that people received their care in a joined up way. The service had a quality assurance system which included planned audits. Records seen by us showed that people who lived in the service, staff and relatives were asked for their views. Any identified shortfalls were addressed promptly and as a result the service was constantly improving. When we spoke with a GP they told us that they believed that the service was well run and was a positive place for people to live. Staff told us that they felt well supported by the manager.

We visited Berwick Grange and observed the support that was offered by the service. We also looked at associated documentation held by the service. We found that people were happy living in the home. One person who used the service told us “I love it here. The staff are very helpful and kind. It feels like home”. We saw that staff were respectful and mindful of people’s dignity and privacy.

Care plans and risk assessments were thorough and regularly updated. People themselves and families were involved in reviews and updating plans to ensure that the support people received was appropriate for them. We found that there was adequate nutrition provided and people were generally happy with the quality of the food provided. The staff were monitoring people’s intake of food and drink appropriately.

The service made referrals to other services and organisations where needed and sought appropriate input from medical and health professionals when it was required. Staff were subject to a formal recruitment process and all the associated documentation was in place. A thorough induction process was completed by all staff.

There were thorough quality assurance systems in place which were followed by staff and there were opportunities for people who used the service, relatives and staff to feedback any issues or ideas. The service then acted on these appropriately.

Berwick Grange was purpose built, and every bedroom had its own bathroom facilities. The home was bright and clean, and there were lots of activities going on during our visit. The activities were appropriate, and people were engaged in the things that were happening.

People who used the service told us that they were happy living there, and relatives told us that they were very satisfied with the care and support their relatives received. One relative told us “They are patient, kind, caring. My relative is well cared for”. One person who used the service told us “I feel happy living here”. Another relative told us “Staff are really happy for me to be involved and encourage it. I’m happy that he is here”.

We looked at the cleanliness of the home, and the suitability of the environment. It was noted that the home could be odorous at times, and there were no specific stimuli provided for people with dementia. Infection control guidelines were followed, and staff showed a good understanding of the ways to minimise risk of cross infection.

We looked at medication administration and found that people were given medication at appropriate times, and medication was stored, dispensed and disposed of appropriately. We also looked at records and documentation and found this to be comprehensive, person centred, regularly reviewed and up to date.

During the visit people who were able told us that the staff were nice and always polite. They also said that staff always come when you need them. They said that they are able to follow their own routines and receive help when they need it. They knew who the manager was and would talk to her if they had any concerns. People also said that they enjoyed the food.