A comprehensive inspection visit took place on 9 October 2018 which was unannounced. We returned announced on 11 October 2018 to conclude our inspection visit.

Oldbury Grange is a nursing home, which provides care for up to 89 people over two floors in three units. Anchor House on the ground floor provides mostly residential accommodation for people, some who are living with early on-set dementia. Hayes House on the first floor provides nursing care and Remember Me is a unit for people with more advanced dementia care needs. At the time of our inspection there were 89 people living at Oldbury Grange. Most people had their own bedroom although seven were shared bedrooms. Some bedrooms had en-suite facilities whilst others shared communal bathrooms.

People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

A requirement of the service’s registration is that they have 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 and the associated Regulations about how the service is run. The service continues to have the same registered manager.

At our last comprehensive inspection in October 2017, we rated the service ‘Requires Improvement’ overall. This was an improvement as the home had previously been rated ‘Inadequate’ at an inspection in March 2017. At this inspection we found some improvements since the last inspection had been addressed, for example, clinical equipment was clean and in good working order and improvements had been made to ensure decisions made about end of life care were in accordance with the Mental Capacity Act 2005.

However, we also identified a number of new issues at this inspection where the provider still needed to take further action to improve and meet the essential standards and regulations. This was because risks to people’s health were not always managed effectively to promote their health and wellbeing and staffing levels at night were insufficient and did not support staff to provide safe care. The provider’s management and quality assurance systems required greater improvement. The service has therefore been rated 'Requires Improvement' overall and for all five key questions.

The management team were not cohesive and the roles and responsibilities of individual managers were not always clear. In some cases, there was a lack of ownership of tasks to ensure they were completed. Staff did not have a clear understanding of the management structure and delegated roles within the home and did not always feel their opinions and views were listened to.

The provider’s quality assurance systems had failed to pick up a number of issues we identified during this inspection. This included a culture where some staff did not consistently demonstrate the same level of understanding or behaviours in caring for people or show they had the skills or competence to deliver good and effective dementia care. The provider had not operated an effective system to identify trends or areas of risk that they could have addressed to improve people’s experience of the service.

On the day of our inspection visit, there were enough staff on duty to keep people safe. However, we could not be assured the registered manager had fully risk assessed people’s dependencies at night to ensure adequate levels of cover within all areas of the home and that staff could respond safely to emergencies. Following our inspection, the provider confirmed staffing levels had been increased at night.

People's care plans included risk management plans for staff to follow, which were regularly reviewed and updated. However, there

We inspected this service on 10 October 2017. The inspection was unannounced.

Oldbury Grange provides accommodation, personal and nursing care for up to 89 people. The home has two floors; the ground floor provides nursing and residential care to older people living with complex health conditions. The first floor has two units; one nursing and one for people living with dementia. The home provides end of life nursing care. At the time of our visit there were 62 people using 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.

At our previous inspection in March 2017, we found a breach in the governance of the home and the legal requirements and regulations associated with the Health and Social Care Act 2008 were not being met. We found breaches of the regulations related to managing risks to people's safe care and treatment, ensuring only fit and proper persons were employed and the requirement to display performance ratings. We gave the home an overall rating of inadequate. The service was placed in 'Special Measures'. The special measures framework is designed to ensure a timely and coordinated response where we judge the standard of care to be inadequate. Services in special measures are inspected again within six months following the publication of the inspection report. The provider accepted a voluntary restriction on any new admissions to the home while they were in special measures.

At this inspection we looked to see if the provider and registered manager had responded to make the required improvements in the standard of care to meet the regulations. Whilst we found that sufficient improvements had been made to remove the service from 'special measures,' we found further breaches of the regulations relating to consent and equipment. We also found improvements were required in how senior managers assured themselves that improvements in service delivery were developed and sustained in the future.

Following our inspection in March 2017 the provider recognised they needed external support to improve the quality of the service. They appointed a ‘consultant manager’ to provide them with guidance and advice. The consultant manager had implemented a new management structure which provided a clear scheme of delegation within the home. Job descriptions had been refined so staff had a better understanding of their own role and responsibilities. The consultant manager was confident that action taken to improve the management of staff so they felt listened to would increase staff motivation and result in better outcomes for people. However, this was an area that required more work as there was still a culture of staff concerns not always reaching the management team.

The systems to assess and check the safety and responsiveness of the service had improved, but needed to become embedded in every day practice to be completely effective. For example, the checks had not identified some clinical equipment had not been maintained and was dirty and that documentation around end of life care was not accurate. This meant there was an increased risk of cross infection and people's end of life wishes might not always be met.

There had been improvement in the assessment and management of individual and environmental risks within the home. Where people had fallen, their risk management plans had been reviewed and updated. However, there were still areas where plans to minimise risks were not consistently followed and records updated.

There were enough staff on each rota to provide safe, effective care but unexpected levels of absence, especially, at weekends could impact on the quality of care people rec

The inspection took place on 22 and 23 March 2017. The visit was unannounced on 22 March 2017 and we informed the provider we would return on 23 March 2017. We gave feedback about concerns we had identified to the registered manager and managing director on 23 March 2017. Two inspectors returned, unannounced, on 4 April 2017 to check if immediate actions had been taken by the registered manager to address issues we identified.

Oldbury Grange provides accommodation, personal and nursing care for up to 89 older people. The home has two floors; the ground floor provides nursing and residential care to older people living with complex health conditions. The first floor has two units; one nursing and one for people living with dementia. The home provides end of life nursing care to people. At the time of the inspection 79 people lived at the home.

The home is required to have 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. At the time of this inspection the home had a registered manager in post, who is also the nominated individual of the service.

When we inspected Oldbury Grange in January 2015, we found breaches of the regulations relating to cleanliness and infection prevention and control and staffing levels, we gave a rating of ‘requires improvement.’ At our last inspection in May 2016 we found some improvements had been made and the regulations were met. However, further improvements were required and we gave a rating of ‘requires improvement.’ We asked the provider to send us a report to tell us what action they had taken to make further improvements. We received an action plan from the registered manager, and the managing director telling us about improvements that had been implemented.

At this inspection we found planned improvements had not been made or sustained.

Risks to people’s health and welfare had not always been identified or assessed and actions to minimise the risk of harm or injury to them had not been taken. Where risks to people had been identified, actions for staff to take to minimise those risks were not detailed which meant staff did not have the information to tell them how to minimise identified risks of harm and injury to people.

Accidents and incidents were not always reported or recorded in a consistent way. Where people had sustained injuries, such as from falling, their ‘falls risk assessment’ was not reviewed by staff to determine ways to reduce the risk of further falls.

The provider did not have suitable arrangements in place to deal with emergencies that might arise from time to time. Some people did not have a personal emergency evacuation plan in the file we were told would be given to the emergency services. The registered manager informed us they did not have enough first aid qualified staff to ensure there was a staff member on each shift who was competent to deal with first aid emergencies that might arise.

The provider did not have a safe system of recruitment in place. Checks had not always been carried out on people working at the home to ensure they were of good character. Where checks had been completed on workers and identified a potential risk, we found risk assessments had not been completed by the registered manager.

Overall, staff felt there were enough of them on each shift. However, some people felt more staff were needed and we observed there were not always sufficient numbers of suitable staff to keep people safe and meet their individual needs.

Staff told us they understood what constituted abuse and would report any concerns they had to the registered manager. The matron and registered manager, overall, knew what abuse was and generally sent u

The inspection took place on 3 and 4 May 2016. The visit was unannounced on 3 May 2016 and we informed the provider we would return on 4 May 2016.

Oldbury Grange provides accommodation, personal and nursing care. Since our last inspection, an extension has been built and the home is now registered for up to 89 older people. The home has two floors; the ground floor provides nursing and residential care to older people living with complex health conditions. The first floor has two units; one nursing and one dementia care. The home provides end of life nursing care to people. At the time of the inspection 79 people lived at the home.

The home is required to have 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. At the time of this inspection the home had a registered manager in post.

At our previous inspection in February 2015 we found two breaches in the legal requirements and regulations associated with the Health and Social Care Act 2008. People were not always protected against the risks of acquiring an infection because appropriate standards of cleanliness and hygiene were not maintained. People’s safety and welfare was not always ensured because there was not sufficient staff available at all times to meet their needs. We rated the home as ‘Requires Improvement’ and asked the provider to send us a report to tell us what action they had taken to become compliant with the regulations.

At this inspection we found improvement had been made to the extent that the provider was no longer in breach of the regulations. However, some further improvement was still required. The registered manager informed us that they had recently recruited ten new staff members as a number of staff had recently left. Some of the improvements needed, identified during this inspection, stemmed from the number of new staff on shift who had not worked at the home long enough to know the people they cared for, and to receive all the training required to work effectively. Plans were in place to provide training to new staff in May and June 2016. Improvement had been made to the environment taking into consideration the needs of people living with dementia. Whilst most staff had completed dementia awareness training, further specialised dementia care training was planned for existing and new staff.

We found people had their prescribed medicines available to them, however, we saw insufficient checks were made by staff to ensure people had consumed their prescribed food supplements and creams applied as needed. Assessments were in place to identify risks to people but risks were not managed consistently by staff because they did not always have the information or training they needed.

Staff worked within the principles of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. The manager understood the Act and made referrals when needed but had not always fully considered their responsibilities under this law in using bed rails for people.

We saw nutritious meals were available to people. However, choices were not always offered and people were not always offered the support they needed to eat their meal. Staff told us they felt there were enough staff allocated to each shift, although new care staff were still getting to know people and their needs.

People’s care records were not sufficiently detailed to support staff in delivering care in accordance with people’s needs and wishes, and staff were not always able to tell us about people’s needs. A range of social activities were offered to people and met the needs of some people.

Systems were in place to assess the quality of the service provided. Some audits wer

We inspected Oldbury Grange Care Home on 13 January 2015. It was an unannounced inspection.

Oldbury Grange has two floors and provides personal and nursing care for up to 61 people. At the time of our inspection there were 59 people living at the home. There is a communal lounge on both floors and a communal dining room on the ground floor. There is an activities room on the ground floor and a small quiet lounge on the first floor.

A requirement of the service’s registration is that they have 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. There was a registered manager in post.

At our previous inspection in August 2014 we found there were four breaches in the legal requirements and Regulations associated with the Health and Social Care Act 2008. We asked the provider to make improvements in staffing, management of medication, safeguarding people from harm and care and welfare. On this inspection we checked to see whether the improvements had been made. We found the management of safeguarding issues and medicines in the home had improved since our previous inspection. Further improvements were needed in the deployment of staff within the home and ensuring care plans matched people’s needs.

People told us they felt safe living at Oldbury Grange and staff we spoke with demonstrated a good understanding of their role in keeping people safe. We found the deployment of staff within the home sometimes left communal areas unattended so people were left without support if they needed it. We also found that infection control procedures required improvement so that people were protected against the risk of infection.

Medicine administration procedures were in place to assist staff in managing medicines appropriately. The provider ensured people’s medicines were available as required and administered as prescribed.

People told us they thought staff had the skills to meet their needs safely and effectively. Staff received support from the management team to gain further qualifications and attend training. We observed occasions when staff did not put their training into practice, for example when supporting people with a diagnosis of dementia.

People were supported to have adequate nutrition and hydration. Where people had nutritional risks, nursing staff had sought advice and intervention from external healthcare professionals to ensure those risks were managed. People were also referred to other external healthcare professionals when a need was identified.

During our visit we found inconsistencies in the provision of care within the home. We observed some very caring interactions between staff and the people they provided support to. Staff were reassuring and engaged positively with people. We also observed times when staff failed to take opportunities to engage and speak with the people they were supporting. There were times when staff failed to explain what they were doing to people who were living with a diagnosis of dementia.

There was a lack of information in people’s records about how they wanted to be cared for when they were approaching the end of their life. There was a risk that the wishes of people and those closest to them would not be respected in the lead up to and when people reached the end of their life.

Care records did not always reflect the care people required to support their personal and nursing care needs. There was also limited personal information so we could not be sure people received support that met their individual preferences.

There was a management team in place with delegated responsibilities. Staff spoke positively about the support they received from the management team who operated an on call system to enable staff to seek advice in an emergency.

The checks in place to monitor the quality of service provision had not identified some of the concerns we found during our visit.

One of the directors of the provider company was also a doctor who provided GP support to the home. They assured us there were no conflicts of interest because all service users had a choice as to which GP practice they registered with.

You can see what action we told the provider to take at the back of the full version of the report.

Two inspectors and a pharmacy inspector visited Oldbury Grange which is registered to provide personal and nursing care for up to 61 people.

During our visit we spoke with the manager, the deputy manager, five care and nursing staff, seven people and six relatives.

We spent time in the communal areas of the home and observed the care and support provided to people. We looked at care records and staff records. We used all the information we gathered during our visit 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. If you would like to see the evidence supporting our summary please read the full report.

Is the service safe?

People who lived at Oldbury Grange told us they felt safe living there. One person told us, “I feel quite safe and if there is anything we want, we just have to ask for it.”

We looked at the care records for seven people. Care plans were available for most of the identified needs. Some care records did not provide staff with the information they needed to manage people’s needs appropriately. For example, their psychological and nutritional care needs.

A pharmacist inspector from the Care Quality Commission looked at medicine management and viewed medicine administration records for 13 people. We found appropriate arrangements were not always being undertaken to manage the risks associated with the unsafe use and management of medicines.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DOLS) which applies to care homes and hospitals. We saw there were some restrictions placed on people’s care such as the use of bedrails. We were told there had been no applications to the local authority to enable any restrictions to be appropriately assessed and agreed. There was a lack of staff awareness of the latest guidance and information on DoLS. This meant staff may not take the appropriate actions to make sure people’s rights were protected.

Is the service effective?

Most people and relatives we spoke with were satisfied with the level of care provided within the home. Relatives told us staff acted upon their requests. One relative told us, “They are very good and a support to me.” A person we spoke with told us, “They have got everything here for you. You can go out when you want to.”

We did not see there was sufficient social activities and tactile stimulation to meet the needs of all the people who lived at the home. In particular for those with psychological and dementia care needs.

During our visit we heard people call out for assistance. Sometimes there was not always a staff presence in areas of the home which meant these people received a delayed response.

Staff we spoke with told us they communicated with one another regularly so they were kept informed about people’s changing needs and how they were managed.

We could not confirm that all staff had completed the appropriate training as training information was not in a format to enable us to do this. We saw individual training records had been commenced to document the training staff had completed.

Is the service caring?

During our visit we saw some positive interactions between staff and people who used the service but these were mostly task orientated. We saw staff were busy and had limited time to spend talking with people.

We saw staff supported one person to smoke by accompanying them outside.

People and the relatives we spoke with were complimentary about the staff working within the home. Comments included. “The two in the dark blue are the best ones.” “I couldn’t look after myself and I think they do extremely well here. They are very, very nice, the younger ones it is a job but they are very pleasant.”

Staff we spoke with told us they liked working at Oldbury Grange.

Is the service responsive?

The provider of the home is a practicing GP and provided the healthcare support to most of the people who lived at Oldbury Grange when required.

We found care records were not always effectively completed and audited to make sure people’s changing needs were identified and effectively addressed.

Is the service well-led?

Whilst people and relatives were positive in their comments of the service, our inspection process identified a number of areas needing improvement.

At our inspection on 09 April 2013, we found that infection control processes were not adequately protecting people from the risk of cross infection. We said that improvements must be made.

We received an action plan from the provider telling us what they were going to do to ensure the necessary improvements were made.

We carried out this visit to check that improvements had been made and to confirm the service was now compliant. The visit was unannounced so that no one living or working in the home knew we were coming.

We found that changes to the environment and new equipment provided had improved the standards of hygiene in the home. We saw that communal areas and people’s rooms were all clean and free from offensive odours.

We saw that disposable protective clothing such as plastic aprons and gloves were readily available to staff throughout the home.

Systems had been implemented by management to monitor and assess infection prevention and control systems.

This meant that people and their visitors were supported by staff who understood the need for good hygiene measures and how this was important in order to reduce the risk of infections.

We therefore, judged that the compliance action set at the last inspection had been complied with.

During our visit to Oldbury Grange Nursing Home we met with most of the people using the service. We spoke with three people in more depth about their experience of care. We also met and spoke with six visiting relatives, the matron and five members of the care staff team.

We were not able to speak with some people who used the service because of their complex needs. However we noted they looked comfortable in their surroundings and smiled at staff when being supported with their care.

One person who lived at the home told us they were happy with the way staff provided their care. They told us, “It’s quite good here and the staff are okay.” A visitor told us that all the staff were, “very nice” and that they “couldn’t fault them.”

We spent time observing the mid day meal and could see people were happy with their meals. One person told us, “We have good food.”

We found that infection control processes were not adequately protecting people from the risk of cross infection.

Staff maintained their knowledge and skills through regular training, updates, support and planned supervisions.

People were confident to raise concerns with the service. One visiting relative said, “I’ve got no concerns but I would tell them if there was a problem.