This inspection took place on 24 July 2018 and was unannounced.

Middletown Grange 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.

Middletown Grange accommodates up to 60 people in one adapted building. At the time of the inspection, the home accommodated 56 people across two separate units, each of which have separate adapted facilities. One of the units specialises in providing care to people living with dementia.

There was no registered manager in place. 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 had left a week before our inspection. The provider had brought in two registered managers from their other homes to share management responsibilities whilst they were recruiting a new manager.

Before the inspection we had received concerns citing staff shortages and poor leadership and management of the home. A week prior to our inspection the registered manager had left. The provider implemented an action plan to ensure people’s safety which the management team were working through.

We found the provider had made some improvements in the last week to ensure people’s safety. However, they were still working through their action plans and there were still some areas to improve. We found the home did not have enough staff to meet people’s needs. The provider had taken action to rehire previously dismissed staff to ensure people were safe. The home continuously recruited staff to ensure people’s needs were met. The home had staff vacancies which were covered by regular agency staff. The home had robust recruitment procedures and conducted background checks to ensure staff were suitable for their roles.

Risks to people’s well-being were assessed and managed safely to help them maintain their independency. Staff were aware of people’s needs and followed guidance to keep them safe. However, some risk assessments were not always reviewed when people’s needs changed.

The environment on the dementia unit was not always clean. We found the unit had malodours both in people’s rooms and in communal areas. The management team told us the provider was in the process of refurbishing the whole home and reviewing the cleaning audits.

People had their needs assessed prior to living at Middletown Grange to ensure staff were able to meet people’s needs. However, the home had failed to ensure that the needs of people living in the dementia unit could be met as the staffing levels were not appropriately adjusted.

People were not always supported with hydration needs. We saw some people on the dementia unit did not have access to call bells and drinks. Staff provided people with regular refreshments, however, people were not supported to drink them.

The service did not always follow best practice in the end of life care. Low staffing levels impacted on how people received end of life care. People’s records were not always up to date.

People knew how to complain and some complaints were dealt with in line with the provider’s complaints policy. However, the concerns we had received prior to our inspection showed that some people’s concerns had not been addressed to their satisfaction.

The service was not always well-led. Historically, Middletown Grange had not had stable leadership. People, their relatives and staff were not happy with the way the service was run. The shortage of staff we identified had had a negative effect on general staff morale. Staff felt let down by the provider and not listened to.

The provider had a range of

We inspected this service on 21 March 2017. Middletown Grange nursing home is registered to provide accommodation for up to 60 older people some living with dementia who require personal or nursing care. At the time of the inspection there were 53 people living at the service.

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 registered manager worked closely with the deputy manager.

At the last inspection on 10 February 2016, we asked the provider to take action to make improvements and make sure people received activities, stimulation or engagement which met their needs and staff engaged with people and ensured care was person centred. Also to ensure the provider assessed, monitored and mitigated the risks relating to the health by managing accidents and incidents. At this inspection on 21 March 2017 we found the actions had been completed.

People had access to activities and stimulation from staff in the home. Activities were not always structured to people's interests, however, the variety had improved. Staff engaged meaningfully with people and ensured care was person centred.

The provider effectively assessed, monitored and mitigated risks relating to health, safety and welfare of the people. There were systems in place to record, investigate and manage accident and incidents.

People who were supported by the service felt safe. Staff had a clear understanding of how to safeguard the people and protect their health and well-being. People’s medicines were stored and administered safely.

There were enough suitably qualified and experienced staff to meet people's needs. People had a range of individualised risk assessments in place to keep them safe and to help them maintain their independence. Where required, staff involved a range of other professionals in people’s care.

The registered manager and staff had a good understanding of the Mental Capacity Act 2005. Where people were thought to lack capacity, assessments in relation to their capacity had been completed in line with the principles of MCA. The registered manager and staff understood their responsibilities under the Deprivation of Liberty Safeguards (DoLS); these provide legal safeguards for people who may be unable to make their own decisions.

People received care from staff who understood their needs. Staff received adequate training and support to carry out their roles effectively. People felt supported by competent staff who benefitted from regular supervision (one to one meetings with their line manager) and team meetings to help them meet the needs of the people they cared for.

People’s nutritional needs were met and people had a good dining experience. People were given choices and received their meals in timely manner. People were supported with meals in line with their care plans.

There was a calm, warm and friendly atmosphere at the service. Staff we spoke with were motivated and inspired to give kind and compassionate care. Staff knew the people they cared for and what was important to them. People's choices and wishes were respected and recorded in their care records.

Where people had received end of life care, staff had taken actions to ensure people would have as dignified and comfortable death as possible. End of life care was provided in a compassionate way.

Leadership within the service was open and transparent. The provider had quality assurance systems in place. The provider had systems to enable people to provide feedback on the support they received.

The registered manager informed us of all notifiable incidents. The registered manager had a clear plan to develop and improve the home.

We inspected this service on 10 February 2016. This was an unannounced inspection. Middletown Grange Care home is registered to provide accommodation for up to 56 older people living with dementia who require personal care. At the time of the inspection there were 43 people living at the service.

We carried out an unannounced focused inspection of this service on 05 August 2015. We found a breach of a legal requirement. This breach was in relation to people not receiving activities, stimulation or engagement which met their needs or preferences. Staff did not always engage with people and ensure care was person centred.

We found some improvements had been made at this inspection. People had access to activities and stimulation from staff in the home. However, these were not person centred. Activities were not always structured to people's interests. Relatives told us there wasn't always much to do. However, other people told us they were happy. We discussed these concerns with the registered manager, who informed us a new activity co-ordinator’s post had been advertised, and staff were to receive coaching on dementia care and activities.

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 registered manager worked closely with the area manager.

People who were supported by the service felt safe. The staff had a clear understanding on how to safeguard the people and protect their health and well-being. There were systems in place to manage safe administration and storage of medicines. There were enough suitably qualified and experienced staff to meet people needs.

People had a range of individualised risk assessments in place to keep them safe and to help them maintain their independence. Where required, staff involved a range of other professionals in people’s care. Staff were quick to identify and alert other professionals when people’s needs changed.

People received care from staff who understood their needs. Staff received adequate training and support to carry out their roles effectively. Staff understood their responsibilities under the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS); these provide legal safeguards for people who may be unable to make their own decisions.

People were supported to have their nutritional needs met and the dining experience was pleasant. However, the upstairs dining room looked overcrowded. People were given choices and received their meals on time. We observed people during lunch time and saw people being supported with meals.

There was a calm, warm and friendly atmosphere at the service. Every member of staff we spoke with was motivated and inspired to give kind and compassionate care. Staff knew the people they

cared for and what was important to them. Staff appreciated people’s unique life histories and understood how these could influence the way people wanted to be cared for. People's choices and wishes were respected and recorded in their care records.

Where people had received end of life care, staff had taken actions to ensure people would have as dignified and comfortable death as possible. End of life care was provided in a compassionate way. Staff had also identified they needed more training in this area and the manager was arranging it.

People felt supported by competent staff. Staff benefitted from regular supervision (one to one meetings with their line manager) and team meetings to help them meet the needs of the people they were caring for.

The manager informed us of all notifiable incidents. The service had good quality assurances in place. The manager had a plan to develop and improve the home. Staff spoke posi

We inspected Middletown Grange on 5 August 2015. Middletown Grange provides nursing care for people over the age of 65. Some people at the home were living with dementia. The home offers a service for up to 56 people. At the time of our visit 53 people were using the service. This was an unannounced inspection.

We carried out an unannounced comprehensive inspection of this service on 9 and 10 April 2015. We found a number of breaches of the legal requirements. These breaches were in relation to short staffing within the home and concerns that people were not receiving safe care and treatment. Staff did not always receive supervision and support from the management. People's care records were not always current and accurate and service was not always well led. The service did not always inform us of notifiable events. Following our inspection, we issued a warning notice to the provider requesting they take action to meet the fundamental standards in relation to staffing and good governance by 30 June 2015.

We undertook this focused inspection to check the service now met the legal requirements. This report covers our findings in relation to these requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Middletown Grange on our website at www.cqc.org.uk

There wasn't a registered manager at the service. The provider was in the process of recruiting a manager. In the interim the deputy manager was being supported by a registered manager from another of the provider's homes on a day to day basis. 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. A new manager had been employed by the provider and was starting the process to register with CQC.

People did not always have access to activities and stimulation from staff in the home. Activities were not structured to people's interests. People told us there wasn't always much to do, however other people told us they were happy. We discussed these concerns with the deputy manager and covering manager who informed us a new activity co-ordinator had been employed, and staff were to receive coaching on dementia care and activities.

Some staff did not ensure people were assisted to mobilise safely. We raised these concerns with the deputy manager and covering manager who took immediate action to ensure people were assisted to move safely. We were reassured with the action taken and that people were protected from further harm.

There were now enough staff deployed to meet people's needs within the home. Staff had time to meet people's care needs and spend time with people. Some staff raised concerns about staffing on the ground floor, however the manager was managing this situation and people's needs were being met.

People who were at risk of pressure damage were supported to reposition and were protected from further damage. Staff supported people with their dietary needs.

The building had some areas which were in need of refurbishment, communal areas on the first floor were often crowded. We discussed this with the deputy manager and manager covering the home, who had a detailed plan to improve the environment.

Staff received access to support and supervision from the home's senior staff. All staff spoke positively about the support they received.

Staff had good awareness of the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS). People living in the home under a DoLS authorisation were being cared for in the least restrictive way.

People's care plans were current and reflected their needs. Care plans contained detailed information on people, their needs and their life histories. Staff spoke positively about the information included in people's care plans.

The provider informed us of all notifable incidents. The provider had clear audits in place at the home. These audits were used to improve the quality of the service. The deputy manager and covering manager had a clear plan to develop and improve the home. Staff spoke positively about the management and direction they had from the provider.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

On the day of our visit 49 people were using the service. They were supported by a combination of nine care workers and two nurses. We spoke with people who used the service and relatives. We also spoke with two nurses, four care workers, the chef, the training co-ordinator, two activities co-ordinators and the registered manager. An inspector and an expert by experience carried out this inspection. The focus of the inspection was to answer five key questions;

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. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

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

This is a summary of what we found:

Is the service safe?

The service was safe. People were cared for in a safe environment which was appropriately maintained.

People were protected from the risk of malnutrition and dehydration. Care staff completed food and fluid charts where they had concerns over people’s well-being. Care plans had also been updated to reduce the risk of people receiving inappropriate care and treatment.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. During our visit we noted that the registered manager and staff had awareness of DoLS. When people were at risk the home made applications through the appropriate channels to legitimately deprive people of their liberty. We spoke with the manager about the recent high court judgement around DoLS. They told us that they had awareness of this decision and would be attending local training regarding the issue.

Is the service effective?

The service was effective because people told us they were asked for their consent before care tasks were carried out. People's cultural and religious needs were respected. We saw that one person had specific dietary needs in line with their religious needs. We saw that the person was provided with appropriate meals.

Care workers and nurses were appropriate trained and received frequent supervisions. All staff we spoke with felt supported and had clear awareness of people's needs.

Is the service caring?

People we spoke with were complementary about the home. One person said, "it’s lovely here” Another person told us "I think this place is the tops.” A relative said, “The care here is first class.”

We found that people benefitted from kind and caring care workers. We conducted a short observational framework for inspection (SOFI) observation in the one of the homes dining room at lunch. SOFI is used to capture the experiences of any person who may have cognitive or communication impairments and cannot verbally give their opinions on the services they receive. We saw that there were many positive interactions between people and staff. We observed a care worker assisting a person with their meal. We saw that the care worker assisted the person at their pace and ensured they were happy to eat. The care worker encouraged the person and treated them with care and warmth. The person appeared happy throughout our observation.

Is the service responsive?

We found that the service was responsive. For example, we saw that where people’s needs had changed staff took appropriate action. We noted that the service had sought the advice of dieticians to ensure that people were protected from the risks of malnutrition.

We noticed that incident and accident records noted that the service took appropriate action to manage the risks associated with incidents and accidents and ensure the health and welfare of people living at Middletown Grange.

Is the service well led?

We found that the service was well led. The service had a registered manager. Staff we spoke with felt they had clear leadership from the registered manager who always had their door open and would listen to any concerns.

Robust systems were in place to monitor the quality and safety of the service. Systems were in place to protect people from the risk of malnutrition and ensure incidents and accidents were learnt from.

During our inspection, we were unable to speak with some residents due to their complex needs. We spoke to five residents and asked them about various aspects of living at this home. People told us that staff were respectful towards them, and that they received the care they needed. The residents we spoke to were all complimentary about the staff and service, with one resident saying "it's as good as it can get", and another resident told us "it's fantastic, I've never had a problem here".

People told us they felt safe living at Middletown Grange. We spoke to three families, and a resident's friend, who were visiting the service, and they all said the quality of the care was "very good". The residents and families thought staff were well trained for the work they were doing.

We were told people got the help they needed when they asked for it with one person adding "if I need anything I've only got to ring my bell and someone comes." A friend of a resident said "I visit three times a week, and it's always clean".

The manager of the home told us she had recently returned from maternity leave, and had submitted a Registered Manager's application to the CQC.

People were complimentary about the home. They told us that they were provided with appropriate care from kind and responsive staff. They said that the accommodation was clean, well maintained and comfortable.

We inspected Middletown Grange on 9 and 10 April 2015. Middletown Grange provides nursing care for people over the age of 65. Some people at the home were living with dementia. The home offers a service for up to 56 people. At the time of our visit 53 people were using the service. This was an unannounced inspection.

We last inspected in June 2013 and found the service was meeting all of the required standards.

There was not a registered manager at the service. 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.

There was not always enough staff on duty to meet the needs of people. People were not protected from risks as staff did not always have time to to reassure people who were anxious, or support people's wellbeing..

Where people, who lacked capacity to consent, were deprived of their liberty, conditions had been set by the authorising body to ensure people had the care and support they needed to meet their needs. These conditions were not always being met, as there was not always enough staff to meet these needs, which could have a negative impact on people's welfare.

Staff had identified people who could exhibit behaviours which challenged. There were not always  care plans in place to support care staff to meet the needs of these people and protect them from harm. People's care plans did not always reflect their needs. Where people's needs had changed assessments had not been amended to ensure staff had the guidance they needed.

Care and nursing staff did not always have access to effective supervision and appraisal processes. Staff were not always effectively supported to develop professionally. However, staff told us they received support from the management, and spoke positively about the support they received from their colleagues.

The provider and manager had systems in place to manage the quality of the service, however these were not always effective. People's and their relative's views were sought, however these did not always inform changes to the service. Staff did not always feel the concerns they had raised to the manager or provider were acted upon. The provider and manager did not always inform CQC of notifiable incidents.

People were cared for by caring, kind and compassionate staff. Care staff knew the people they cared for, what they liked and what was important to them. People were given choice around day to day decisions such as choice of food and drink.

Nursing and care staff had good awareness of safeguarding and whistle blowing procedures. People told us they felt safe and relatives spoke positively about the way their loved ones were cared for.

Staff understood and acted in accordance with the legal requirements when supporting people who lacked capacity to give consent to care and treatment.

Where people had specific healthcare needs, nursing and care staff had the skills they needed to meet those needs. People's dietary needs were catered for, to ensure people had their nutritional and healthcare needs met.

We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the Health and Social Care Act 2008 (Registration) Regulations 2009. You can see what action we told the provider to take at the back of the full version of this report.