This inspection took place on 02 and 03 October 2018. The first day was unannounced which meant the service did not know we were coming. The second day was by arrangement.

Moston Grange Nursing Home 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.

Moston Grange Nursing Home is owned and operated by EHC Moston Grange Limited, trading as Equilibrium Healthcare, and is registered with CQC to accommodate up to 64 people. At the time of this inspection, 38 people used the service. Nursing care was provided to people living with various forms of neurological disorder such as dementia, acquired brain injury and other forms of degenerative mental health disorders.

We last inspected Moston Grange in March 2018. At that time, we found serious systemic failures and multiple breaches of regulations associated with the Health and Social Care Act (Regulated Activities) Regulations 2014. As a result of this, the service was rated ‘Inadequate’ and placed in special measures. This inspection was planned to check whether the provider was now meeting legal requirements.

At this inspection, we found significant improvements had been made which means the service is no longer in special measures and we have now rated the service overall as ‘Requires Improvements.’ This is because we found one breach of Regulation concerning the safe management of medicines. More widely, where a service has previously been rated Inadequate, to improve the overall rating to 'Good' would require a longer-term track record of consistent good practice, leadership and management. You can see what action we have asked the provider to take at the back of the full report.

A pharmacist from the CQC medicines team looked at medicines and associated records for 15 people and found concerns about the safe and proper management of some medicines for all 15 people. For example, we found inaccuracies with medicine reconciliation; issues related to stock control and the application of medical creams; issues with medicines prescribed ‘as and when required’; and a lack of guidance for staff around thickener’s for drinks.

There were improvements in the way medicines were supplied since our last inspection. Medicines, especially those that were prescribed following a GP visit, were now obtained in enough time so that people could start their treatment promptly.

Before a person was accepted to move into Moston Grange, a comprehensive pre-admission assessment was carried out. As part of the assessment process, a multi-disciplinary panel would meet to ensure the service could meet the person’s needs.

People had assessments in place which identified risks in relation to their health, independence and wellbeing. There were assessments in place which considered the individual risks to people such as mobility, nutrition and hydration, and personal care. Where a risk had been identified there was guidance for staff on how to support people appropriately in order to minimise hazards and keep people safe whilst maintaining as much independence as possible.

We reviewed staffing levels and noted there had been a recent recruitment drive and several new staff had commenced work. Staff we spoke with confirmed there were enough staff on duty to meet people's needs.

We reviewed arrangements for safeguarding and whistleblowing within the service and found wide ranging improvements had been made. All the staff we spoke with knew and understood their responsibilities to keep people safe and to protect them from harm.

At the time of this inspection, Moston Grange was undergoing an extensive refurbishment programme. In designing the layout and decoration, the management team had ensured this was done to meet national best practice guidelines for creating an environment t

This inspection took place over two days on 26 March and 27 March 2018. The first day was unannounced, which meant the service did not know in advance we were coming. The second day was by arrangement.

Moston Grange Nursing Home 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. Moston Grange Nursing Home is owned and operated by EHC Moston Grange Limited, trading as Equilibrium Healthcare, and is registered with CQC to accommodate up to 64 people. At the time of this inspection, 48 people were living at the service.

Accommodation is arranged over five units; Deanvale, Mapledene, Woodside, Hollybank View and Hollybank Vale. Nursing care is provided to people living with various forms of neurological disorder such as dementia, acquired brain injury and other forms of degenerative mental health disorders.

We last inspected Moston Grange Nursing Home in July 2017. At that time, we found breaches of legal requirements and the home was rated ‘requires improvement’ in all areas. We also took enforcement action by serving three warning notices in respect of safe care and treatment, safeguarding people from abuse and improper treatment, and good governance. We had scheduled a date to return back to Moston Grange to check on progress. However, in the intervening period since our last inspection, CQC received information of concern that was of a safeguarding nature. In response to this, we raised a safeguarding alert with the local authority and brought forward the scheduled inspection. We also shared these concerns with a senior manager from Equilibrium Healthcare so that immediate action could be taken to ensure people who used the service were safeguarded. However, these matters had been fully investigation by the provider and none of the allegations subsequently resulted in any formal disciplinary sanction being issued against staff.

At this inspection we found the service had failed to make sufficient progress or achieve compliance in respect of the three warning notices issued following our last inspection. This meant there was a continuing breach of regulations and a failure to act on past risks that were already known to the service provider. We also made a recommendation following this inspection with regards to equality and diversity. We are currently considering our enforcement options in regards to these continuing breaches. Full information about CQC's regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

During a tour of the premises, we found people who used the service were exposed to a risk of harm caused through the inappropriate storage of equipment in a communal bathroom, a storage cupboard with a broken lock that contained razor blades and medicinal creams, and a sluice room containing hazardous substances that had been left unlocked.

We found continued failures in respect of the delivery of safe care and treatment and how risks to people who used the service were identified and mitigated. In particular, risks associated with the management of people with complex needs, those deemed at a high risk of malnutrition, and those at risk of pressure sores.

The safe management of medicines was not consistent across the service. We found inconsistencies in recording when a PRN (as and when required) medicine had been given, the medicine round on one unit took an extended period of time to complete, which meant people were at risk of not receiving their medicines in a timely manner or as prescribed and medicines competency checks were not always completed with staff who had responsibility for the management and administration of medicines.

Aspects of the home were found to not be visibly clean

This inspection took place on 11 and 12 July 2017. This inspection was unannounced, which meant the service did not know in advance we were coming.

Moston Grange Nursing Home is registered to provide nursing care and accommodation for up to 64 people who require treatment or support. At the time of this inspection there were 53 people living in the home.

Accommodation is arranged over five units within two single-storey residential buildings. Deanvale and Mapledene Units provide care for both adult men and women. Woodside Unit provides support to adult men with a neurological/degenerative disorder. Hollybank Unit has been split into two smaller environments to enable staff to cater for people whose behaviours may challenge others. Each unit has access to their own individual enclosed garden. Moston Grange Nursing Home is situated within walking distance of Newton Heath and Failsworth.

Our last inspection took place on 06 and 08 September 2016 when we gave an overall rating of the service as 'Requires Improvement'. We found a single breach of the legal requirements in relation to Person centred care. At this inspection we found that the service was now meeting this regulation however we found breaches of three other regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to safeguarding service users from abuse and improper treatment, safe care and treatment and good governance.

You can see what action we have told the provider to take at the back of the full version of this report. We are currently considering our options in relation to enforcement and will update this section once any enforcement action has concluded.

The home had 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 was supported by two deputy managers who were responsible for managing the units.

Staffing levels were structured to meet the needs of the people who used the service. However, some people felt the home needed to recruit regular staff rather than relying on the continued use of agency staff.

Systems were in place to deal with any emergency that could affect the provision of care, such as a failure of the electricity and gas supply. However, we found the home did not have records of fire drills since 2015. The registered manager was confident these drills had taken place recently, but couldn’t locate the evidence of these fire drills during the inspection. Shortly after the inspection the registered manager provided copies of fire drills carried out. However, we noted the last fire drill was completed in November 2016. We have made a recommendation that the registered provider reviews the latest fire safety guidance for care homes.

People had access to health care professionals to make sure they received appropriate care and treatment. However, prior to our inspection we spoke with a healthcare professional who felt there was a breakdown in communication in relation to specialised equipment not being ordered in a timely manner by the home. We discussed this further with the deputy manager who wasn’t aware the healthcare professional had concerns about the home. A safeguarding meeting has been scheduled and we will review the outcome of this meeting once concluded.

The provider was in the process of implementing a new care planning system that aims to make the care planning documentation more person centred. However, in one person’s care plan we noted there had been a discrepancy in a person not having their blood glucose levels monitored by the home. This resulted in the person not having their blood glucose levels monitored for over six months, which could hav

The inspection took place on 6 and 8 September 2016 and was unannounced.

Moston Grange Nursing Home is registered to provide nursing care and accommodation for up to 64 people who require treatment or support. There are four individually named single-storey residential houses. Deanvale, Hollybank and Mapledene which provides care for both men and women, and Woodside providing care for men only. There is a separate central administration block which lies in between the houses. During our visit there were 59 people residing at the home.

The home had 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 was supported by a deputy manager and a clinical nurse manager who ensured the home ran well.

Checks were made to the premises, servicing of equipment and fire safety. Staff told us there was enough equipment available to promote people’s safety and independence. We saw people being supported appropriately with hoists and with wheelchairs.

Improvement was needed to ensure there were sufficient numbers of staff deployed to meet the

needs of all people living at the home. There was a plan in place to address the issue of staffing with more staff being employed over the coming weeks.

People had their nutritional needs assessed and were provided with a diet which met their preferences. There was mixed feedback about the food but people told us there was always a choice of meals and they had enough of it.

Staff received appropriate training to ensure they were competent to meet people’s needs however we saw agency staff used did not support people in the correct way. We found more could have been done to ensure people were supported effectively by staff who knew them well.

People received their medicines safely from staff who had received specialist training in this area and were offered prescribed pain relief regularly to maintain their comfort.

Systems were in place to safeguard people from abuse. Staff we spoke with were knowledgeable about the correct procedures to follow to ensure people were kept safe and the home followed the correct processes to ensure people were not unlawfully deprived of their liberty.

Some areas of the home were not well maintained and attention was needed in some bathroom and toilet areas.

A safe system of staff recruitment was in place. This helped to protect people from being cared for and supported by unsuitable staff. Disciplinary processes were effectively used, to manage poor performance of staff, when required.

We found improvement was needed to ensure each person had an opportunity to engage in meaningful and stimulating conversations or activities. We recommend the home accesses best practice guidance to promote the health and wellbeing of people who are living with dementia.

We also found a breach in relation to person centred care as not all people received an appropriate level of care at all times.

You can see what action we have asked the provider to take on the back page of this report.

An adult social care inspector carried out this inspection. This was a follow up inspection as the provider had been non -compliant in one outcome at the previous inspection.

As part of this inspection we observed people who use the service, the registered manager, and three care staff. We also reviewed seven care records, daily care records and medication administration records.

Below is a summary of what we found. The summary describes what the staff told us, what we observed and the records we looked at.

Is the service safe?

There was a staffing rota in place and staff told us they felt there was enough staff on duty at any time. All staff felt they received plenty of training and felt competent to do their job. A member of staff told us “Yes there are enough staff here even to do the 1:1.”

Is the service effective?

People's needs were being met at the home. We found that people's needs were assessed and care files included information about people's diagnosed health conditions and also their preferences.

Is the service caring?

We observed that staff providing people's care were kind and encouraging and spoke to people in a friendly manner.

People appeared to be treated with dignity and the staff could tell us what they were able to do to maintain a person’s dignity. One member of staff told us 'I always knock on people's door.'

Is the service responsive?

People’s needs had been assessed before they moved to the home. People’s records identified personal preferences and choices and the support that needed to be provided.

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Is the service well-led?

Staff felt listened to and supported by their manager.

Two inspectors and an expert by experience carried out this inspection on the 10 July. Part of the purpose was to follow up a ”dementia themed” inspection which was carried out in February 2014. A 'dementia themed' inspection focusses specifically on the care and support provided for people living with dementia. During our inspection in February we found Moston Grange was not meeting four standards and we required the service to tell us how they were going to improve. On this inspection we spent most of our time on two units, as this is where we previously identified the majority of our concerns. We looked to see whether these standards were now being met and included another standard to check people were respected and involved in their care and support needs.

On the day of our inspection there were 55 people living at Moston Grange. We spoke with seven people in different units, two relatives and nine members of staff. We also spoke with the registered manager who has been registered with the Care Quality Commission since March 2014. We looked at a variety of records, including care plans, audit records and policies.

We considered all the evidence we had gathered and used it 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?

This is a summary of what we found. The evidence supporting these findings can be found under our judgements for each standard.

Is the service safe?

We saw documentation in care records that showed us that risks were identified, assessed and measures put in place to minimise any risk of harm. During the inspection we saw that staff were attentive to people who lived at Moston Grange and noted if a person required extra support or reassurance. This showed us that staff responded to people’s needs in a way that minimised the risk of harm. At the last inspection we saw that care records were not accurate. At this inspection we considered that some improvements had been made.

The CQC monitors the operation in care homes of the Deprivation of Liberty Safeguards (DoLS). At Moston Grange there was one person for whom a DoLS authorisation had been applied for at the time of our visit. We discussed the authorisation with the manager during the inspection and it was clear that the manager had a good understanding of the processes in place.

Is the service effective?

The manager had taken action to address our concerns from our last inspection. We saw people had documentation in place that identified their needs and wishes if they attended hospital in an emergency situation. We saw there was a policy in place to inform staff of the correct procedures to follow. We found that improvements had been made.

Is the service caring?

We observed people appeared well groomed and staff interactions were respectful and considerate. We saw documentation that showed us people were encouraged to discuss their wishes and care plan. One staff member told us; “It’s loads better here now, I feel as if I’m enabling people - not just doing a job.” We observed people were asked to make decisions when this was required and that staff were patient when communicating with people who lived at Moston Grange. This showed us that the service was caring.

Is the service responsive?

We saw there was a complaints procedure in place and this was available in an “easy read” format. During the inspection we were told by staff the manager had made considerable changes to improve the service and the home. One staff member told us how there were plans to improve the environment for people who lived on one of the units, and extra staff had been recruited to provide activities for people who lived at Moston Grange. We considered the service was responsive to people’s needs.

Is the service well led?

The registered manager had made considerable changes since the inspection carried out in February. We saw that training had been provided to staff to enable them to deliver safe and effective care, and further training was planned. We noted that the action plan that had been sent to us following the last inspection was on display in the reception area of Moston Grange. We discussed this with the manager who told us; “If I had a relative here I’d want to know how things will improve, and the staff are all aware of the need to change. We need to do this together.” We viewed audits which showed us areas for improvement were identified and action taken as appropriate. We concluded the service was well led.

At the time of our inspection we were informed the home had five units and there were currently 55 people in residence. The service specialised in providing care and support for adults with young onset dementia. All units had a registered nurse on duty during the day. Registered nurses were supported by support staff on each unit. During our inspection we spoke with, or observed approximately 22 people who were using the service.

We were told the service had gone through a management restructure and the operational manager was currently in the process of registering as the homes registered manager with the Care Quality Commission.

We saw the environment had not been adapted to make it more accessible to people with dementia. The manager told us they were aware of initiatives for measuring and monitoring the quality of dementia care but they were not currently in use.

At the last inspection we found records were not securely stored and the provider needed to take immediate action. We found the provider had addressed this issue and records were stored appropriately and securely.

We saw thorough and comprehensive systems in place to record whether someone needed to be kept safe through the use of a deprivation of liberty safeguard (DoLS). These records were properly signed and dated.

We had received a compliant about the lack of activities available and poor communication between staff and people using the service. We carried out an observation using a short observational framework for inspection (SOFI) to measure this.

People told us they were happy with the care they received. One person said they received the "same care [inside the home] as outside the home." Another said: "we all have little moods now and then" and that staff were "very good" and "patient." Other comments from people who used the service included: "staff are here to help you" and "if you want coffee, just ask and it's here within two minutes."

Another person chose the nursing home because it "fits in with what I want" and "I get the same care [in this home] as out of the home." Another person described how the staff "make sure nobody is left out" during group activities.

One family of someone who used the service said "there have been ups and downs, but [our relative] is doing really well" and "this is one of the best homes" they had used. Another family of someone who was trialling the service said the home was "beautiful" and their relative "doesn't want to go back."

One person told us: "I remember when I first came to live here, I wanted to go somewhere else at first, but I like it here now."

When asked, people said they were able to choose when to get up and go to bed and what they want to do during the day. One person said: "The staff are very good here and I feel like it's my home, I do things as I would at home but here, I don't have to do the housework."

People we spoke with said they felt safe living in the home. One person said: "the staff are kind and helpful, I have no complaints."

One person living in the home whilst receiving some support and care said: “Sometimes I'd like to see more of the managers coming around to chat with you but they are approachable and the staff are all lovely, all in all it’s very good here.”