The inspection took place on 8 and 14 March 2018 and was unannounced, which meant the provider did not know we were visiting. At the last inspection in December 2016 the premises and equipment was not always cleaned and maintained and governance systems were not robust. These issues were breaches of regulations 15 (premises and equipment) and 17 (Good governance).

Following the inspection, the provider sent us an action plan to describe how they would address these concerns. At this inspection we found the provider had made improvements which meant they were no longer in breach of the regulations.

Dene Grange is a 'care home'. People in care homes receive accommodation and nursing or personal care as single packages 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.

Dene Grange is a care home providing accommodation in four separate units for up to 50 people with residential and nursing care needs. Some of the people who lived at the service had complex needs, including those who were living with dementia. At the time of the inspection, there were 39 people living at the service.

The service had 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.

People had their needs assessed and care plans with supportive risk assessments were put in place and reviewed regularly. Any accidents or incidents were recorded and monitored for any trends.

Medicines were administered by trained staff. Overall medicines were managed well. A small number of issues were found during our inspection, but the registered manager addressed these immediately.

Staff were aware of their safeguarding responsibilities and told us they would report anything of concern. Regular checks were made on the premises and the equipment used within to ensure it was safe for people. We found that actions from an electrical check had not been finalised, however, the provider arranged this to take place during the inspection. Emergency contingency plans were in place in case of emergencies like flooding or fire and to support people evacuate from the premises if required.

We deemed that there was not enough staff during later shifts at the service. The provider increased the number of staff on duty on night shifts during the inspection. We have also made a recommendation that the provider review staffing and skill mix levels during the day as we found enough staff but the skills mix was not always appropriate.

There were safe recruitment procedures in place and staff were checked prior to starting work to ensure they were suitable for their role and safe to work with vulnerable people. Staff told us they were well supported and received suitable training to allow them to complete their work safely. They told us they could ask the registered manager if they wanted to go on particular training to enhance their skills and this was arranged.

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.

People told us they enjoyed the food prepared for them. We found people received a range of nutritious meals and refreshments to meet their dietary needs throughout the day. Staff supported people who needed help with eating and drinking appropriately and healthcare professionals were positive about the support provided with nutrition.

Arrangements were made for people to see their GP and other healthcare professionals when they needed to. People had been referred for specialist support if that was required, f

This inspection took place on 21 and 22 December 2016 and was unannounced. This meant the staff and the registered provider did not know we would be visiting.

Dene Grange provides accommodation for up to 48 people who require nursing or personal care. At the time of our inspection there were 47 people who were using the service. The home is divided into four separate units over two floors.

At our last inspection of Dene Grange in June 2015 we reported that the registered providers were in breach of the following:-

Regulation 17 Good governance

Regulation 18 Staffing

Following the last inspection on 3 June 2015, the registered provider sent us an action plan and told us what improvements they intended to make. At this inspection we found there were some improvements. However we also found there were further regulatory breaches.

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.

We found people’s medicines were administered by staff who were trained in medicines administration and had been assessed as competent. Medicines were appropriately stored and we observed people being given their medicines with patience and kindness.

Staff underwent the appropriate checks before they began working in the service. There was evidence of the checks carried out on staff files. This meant the registered provider had checked to see if staff were fit to work in the home.

We found a number of concerns in relation to the maintenance of the building and reported our concerns to the regional manager and the registered manager who made arrangements for the work to be carried out. Audits carried out to monitor the quality of the home had failed to address these deficits.

People’s cared documents were up to date and accurate. We found relatives had been involved in ensuring people’s care plans met their needs. Staff were given guidance in the care plans and where people’s needs were more complex the registered manager had arranged training from the community nurses.

We saw the food presented to people at meal times looked appetising and nutritious. People were encouraged and supported to eat by staff. However we found some people had to wait for the support they needed to eat as staff were supporting a number of people.

The service had in place a complaints process. This was displayed in the home and available for people to use. Since our last inspection the registered manager had received one complaint and had carried out a thorough investigation before replying to the complainant. This meant people could be assured their complaints would be appropriately dealt with.

Relatives told us the staff were caring towards their family members. Professionals who visited the service also described the staff in positive terms. Our observations during the inspection included staff demonstrating kindness and respecting people’s dignity and privacy.

Staff were aware of people’s dietary needs and were able to tell us about which people were vulnerable to weight loss and what actions had been taken. They knew which people were prescribed food supplements and when these were to be offered.

We saw the home had made referrals to other services which supported people, for example the behaviour support team, dieticians, chiropodists and opticians. Local nursing teams confirmed the staff if they had concerns they would ask them to visit the person.

Since the last inspection the registered manager had changed the staffing structure of the home. They had introduced more senior roles. Following this inspection we have recommended the registered provider and the registered manager review the levels of staffing to check if there are

The inspection took place on 3 June 2015 and was unannounced.

We carried out our previous inspection in April 2014, where we found a breach of one regulation which related to staffing levels. We carried out a review in September 2014 and found that the improvements had been made and the provider was meeting this regulation.

Dene Grange provides nursing and personal care for up to 50 people, most of whom have dementia related conditions. There were 39 people living at the home at the time of the inspection.

The home was divided into three units, the “male unit,” “railway cottages” and the “nursing unit.” People who lived in railway cottages needed assistance with personal care, with the exception of one person who required nursing care.

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 and associated Regulations about how the service is run.

Some relatives and staff raised concerns regarding staffing levels in the home. There was one nurse on duty to oversee the care of people who required nursing care. A senior care worker had recently stood down from her post which meant that there was no senior care worker on duty through the day. This meant that the nurse had to administer medicines to all 39 people, liaise with health care professionals and complete care documentation. We had concerns about certain aspects of care documentation, medicines recording and social activities which some staff stated were due to reduced staffing levels at the home.

Following our inspection visit, we wrote a letter to the provider using our regulatory powers. We requested information about what action they were going to take to ensure safe staffing levels were achieved and maintained at Dene Grange. We received a response in line with legal requirements which stated that senior care workers, who would support the nursing team, were now in post.

There were safeguarding procedures in place. Staff knew what action to take if abuse was suspected. We spoke with the local authority safeguarding officer who told us that there were no organisational safeguarding concerns regarding the service.

We spent time looking around the premises and saw that the building was generally clean and well maintained. Railway cottages had been recently redecorated and refurbished with a railway theme. At the bottom of the corridor was an indoor garden with artificial turf. There was also a painted window with a garden scene for people to look at. Some relatives told us however, that the outdoor garden areas could we improved.

We checked medicines management. We found some concerns with the recording of medicines which meant it was not always possible to check that medicines had been administered as prescribed.

Staff told us that training courses were available in safe working practices and to meet the specific needs of people who lived there such as dementia care.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS). DoLS are part of the Mental Capacity Act 2005 (MCA). These safeguards aim to make sure that people are looked after in a way that does not inappropriately restrict their freedom. We found that the service had made a number of applications to the local authority to deprive people of their liberty in line with legislation and case law. However, they had not notified us of the outcome of these applications in line with legal requirements. We noted that mental capacity assessments had been carried out. These were not always decision specific. The manager was aware of this issue and decision specific assessments were being put into place.

People and relatives did not raise any concerns about meals at the home. We observed that staff supported people with their dietary requirements. Staff who worked at the home were knowledgeable about people’s needs. We observed positive interactions between people and staff.

There were two part time activities coordinators employed to help meet the social needs of people who lived there. Some relatives and staff stated that more activities were required. We saw some activities being carried out on the nursing unit and railway cottages; however, we did not see any meaningful activities carried out on the male unit. We have made a recommendation about activities provision at the home.

There was a complaints procedure in place. Feedback systems were in place to obtain people’s views. “Residents and relatives” meetings were held and surveys carried out.

Nursing staff informed us that the care documentation was excessive at times. We found there was a number of missing entries in some of the daily records we viewed. One person’s positional chart had not been updated and another person’s bedrail assessment had not been reviewed as planned. Nursing staff informed us that sometimes it was difficult to ensure that all documentation was up to date and accurate because of staffing levels.

A number of checks were carried out by the manager. These included checks on health and safety; care plans; the dining experience; infection control and medicines.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to good governance and staffing. This is the third time we have judged that the provider was not meeting the relevant regulation with regards to staffing levels since October 2012. We considered that action was required to ensure that safe staffing levels were consistently maintained over time. The action we have asked the provider to take, can be found at the back of this report.

We spoke by telephone to a number of health and social care professionals to find out their opinions of the service. These included a GP, a member of the NHS challenging behaviour team and a local authority care manager. They all considered that improvements had been made in the home. We also spoke with an NHS community matron for nursing homes. She informed us that nursing staff always contacted her for advice and support.

Most people were unable to tell us their views because of the nature of their disability or illness; therefore we spoke with seven relatives and one visitor to find out their opinions of the home. They too concluded that improvements had been made.

The manager had been in post for four months prior to our inspection. She was in the process of registering with the Care Quality Commission.

We found that people’s diversity, values and human rights were respected. The member of staff from the challenging behaviour team informed us, “There has been a shift in focus from staff to resident focus.”

We concluded that people’s care and treatment was planned and delivered in line with their individual care plan.

We found that there was enough equipment to promote the health, independence and comfort of people.

We concluded that there were enough staff to meet people’s needs.

We found that the provider had a system in place to monitor the health, safety and welfare of people and people’s personal records were accurate and fit for purpose.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Her name appears because she was still a registered manager on our register at the time.

A new manager had been employed. She had been in post for three weeks prior to our inspection.

Most people were unable to tell us their views because of the nature of their disability or illness. We spoke with two relatives who were complimentary about the care their family members received. One relative told us, "The care is magic.” We saw positive one to one interactions between staff and people who lived there. We concluded that people’s needs were assessed and care and treatment was planned and delivered in line with their individual care plan. Relatives, with whom we spoke, explained they did not have any concerns about the management of nutritional needs at the home. We saw that staff gave people individual support and supervision at mealtimes. We concluded that people were supported to be able to eat and drink sufficient amounts to meet their needs.

The home was set out over two floors. Due to a flood in June 2012, part of the ground floor had been closed and some people were transferred to the first floor. We spent part of the morning observing the care practices on the ground floor. We saw positive interactions there between staff and people. However, because of concerns over the care and welfare of people on the first floor we decided to spend the rest of the day observing the practices there. All the findings written in this report relate to the first floor.

We spoke with two relatives who were complimentary about the care their family members received. One relative told us, “It’s first class” and “They go out of their way to help you.” The other relative said, “You couldn’t wish for anything better. The care is excellent,” “The food is all liquidised especially for her” and “She had a seizure and was looked after great here without going into hospital” and “She’s always in clean clothing, although she hasn’t had her hair done for a while.”

We found that staff practices did not always promote people’s privacy and dignity, or meet their needs and protect their rights.

We found that people were not protected from the risks of inadequate nutrition and hydration and there was not enough equipment to promote the independence and comfort of those who used the service.

We discussed our concerns with senior management at the home. They have started to address these issues immediately.

Thirty six people were living at Sunningdale Lodge Care Home at the time of our visit.

We used different methods to help us understand the experiences of people who were using the service, because people had complex needs which meant they were not able to tell us their experiences.

We spoke with relatives of five people who were using the service. Their comments included, “I checked a few services out before he (my relative) came to live here, I chose this one because of the friendly staff” and “I’m very pleased with it, since it’s been taken over it’s improved a lot. There’s more staff but the laundry could do with improving”.

We observed the care provided by the staff to people who lived in the home and spent time looking around the building. We did not speak to people about the outcome areas we assessed. We spoke with the staff on duty who confirmed they were receiving up to date training to help them carry out their roles effectively.

We considered our inspection findings to answer questions we always ask;

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well-led?

Below is a summary of what we found.

Is the service safe?

We spoke with four relatives and six people to find out their opinions of Dene Grange. We also consulted with a challenging behaviour clinician, care manager, community matron for nursing homes, contracts officer, GP, social worker, two safeguarding officers and a reviewing officer to find out their views. We also spoke with eight members of staff.

People were treated with respect and dignity by the staff. They were cared for in an environment that was safe and clean, although the décor and furnishings were not always planned to meet the needs of people who had dementia. Two people who were able to communicate verbally with us told us that they felt safe. One relative said, “It’s as safe as it can be.” We spoke with the local authority’s safeguarding adults’ team who informed us that there were no ongoing safeguarding issues at the home.

We found that an effective system to manage medication was in place. One person said, “They never forget my medication.”

We had concerns about staffing levels at the home. All staff with whom we spoke informed us that more staff were needed to care for people adequately. Two relatives with whom we spoke also agreed. There was one activities coordinator for the whole of the home and some people’s dependency levels had changed which meant that more care and support were required. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. An urgent deprivation of liberty application had been submitted to the local authority regarding one individual. Following a recent court ruling regarding depriving people of their liberty in care settings, the provider may wish to review people’s living arrangements, to identify where their circumstances may amount to a deprivation of liberty, according to the revised definition.

Is the service effective?

It was clear from our observations and from speaking with staff that they had a good understanding of the people’s care and support needs and that they knew them well. One relative said, “It’s excellent the care.”

Those who were able to communicate verbally informed us that they were happy with the care provided. One person said, “They look after us well.”

Is the service caring?

We saw that care workers showed patience and gave encouragement when supporting people. One person informed us, “The staff are absolutely great.” We saw that people looked well cared for.

Is the service responsive?

People's needs had been assessed before they visited the service. One person informed us that the GP was always called if she was unwell. On the day of the inspection a GP had been called to visit a person who had become unwell. In addition, a clinician in challenging behaviour was visiting the home to help formulate a plan of care for a person whose behaviour had become more challenging. One relative informed us, “It’s amazingly responsive, I bet not many places are like this.” Another relative agreed, “It is responsive. We have relatives’ meetings where we discuss things and they take action.”

Is the service well-led?

People spoke positively about the manager and deputy manager. One relative commented, “It’s well led, the manager and deputy are absolutely excellent.” Another relative said, “I’ve been really impressed with how they handle things, it’s like a big happy family.”

We found that a variety of checks were carried out to monitor the quality of the service. These included care plan; health and safety, medication and dining audits. The regional manager carried out a monthly audit of all systems and procedures at the home.

Meetings were held for people and their relatives. One person said, “We have meetings where we talk about things. We’re very happy people here.” A relative told us, “I feel able to raise things…I have been heard and listened to.”

Staff told us they were clear about their roles and responsibilities. They informed us that regular meetings were held. This was confirmed by minutes of meetings.