We undertook an unannounced inspection of Romford Grange Care Home on 3 and 4 July 2018. Romford Grange Care Home is a ‘care home’. People in care homes receive accommodation and nursing 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. Romford Grange Care Home is a care home for up to 41 older adults. This included people with dementia. At this inspection there were 36 people living in the home.

At our last inspection on 9 June 2017, the home was rated ‘Requires Improvement’. The home was in breach of Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 as we found that the premises were not being maintained. We also found that room temperatures where medicines were stored exceeded recommended levels, activities did not meet people’s needs and robust audit process were not in place to identify shortfalls. At this inspection we found improvements had been made in these areas and the home has been rated ‘Good’.

The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the home. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the legal requirements in the Health and Social Care Act 2008 and the associated regulations on how the home is run.

Risks had been identified and assessed, which provided information to staff on how to mitigate risks to keep people safe. Staff had been trained in safeguarding adults and knew how to keep people safe.

Medicines were managed safely. We found that people’s Medicine Administration Records (MAR) had been completed accurately. Medicines was being administered as instructed on people’s MAR, or in accordance with the provider’s policy. Medicines were stored securely and within accepted temperature levels.

Incident records were reviewed and these showed the provider took appropriate action following incidents that had been recorded. Systems were in place to analyse incidents for patterns and trends to ensure lessons were learnt and incidents were minimised.

Systems were in place to reduce the risk and spread of infection. Staff had access to personal protective equipment and used this when needed.

There were sufficient staffing levels to support people. Dependency assessments were carried out to calculate the number of staff needed contingent to people’s needs. Premises safety checks had been carried out to ensure the premises was safe.

Staff had the knowledge, training and skills to care for people effectively. Staff felt supported to carry out their roles. However, supervisions of staff had not been completed regularly, to ensure staff felt supported at all times. We made a recommendation in this area.

People had choices during meal times and were supported with meals when required. People and relatives told us people enjoyed the food. People’s weights were regularly monitored and referrals made to health professionals if there were concerns with people’s weight. People had access to healthcare services.

Some people who lived at the home were deprived of their liberty under the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). Deprivation of Liberty applications had been made and granted to restrict people’s lawfully. Staff were aware of the principles of the MCA and assessments had been carried out to determine people’s ability to make decisions in certain areas.

People and relatives told us that staff were friendly and caring. Our observations confirmed this. People were treated in a respectful and dignified manner by staff who understood the need to protect people's human rights. People had been involved with making decisions about their care.

People received care that was shaped around their individual needs, interests and preferences. Care plans were

The unannounced inspection took place on 9 June 2017. At our previous inspection there were three breaches of legal requirements. During this inspection we found improvements had been made. However, we noted that the premises still needed to be maintained safely. Some records such as bedrail risk assessments and medicine room temperature checks were not always fully completed and therefore not any accurate record of assessments or action taken. Romford Grange provides personal care to a maximum of 44 people some of whom may be living with dementia. On the day of our visit there were 41 people using the service.

On the day of the visit there had been no registered manager since April 2017. There was an acting manager in place pending recruitment of a 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 told us they felt safe living at Romford Grange. Staff had received safeguarding training and were aware of the procedures in place to protect people from avoidable harm.

Risk assessments were in place and known by staff in order to protect people from harm.

People and their relative had mixed reviews about the staffing. Although enough staff were deployed some people were not happy with the regular use of unfamiliar agency staff. We noted that recruitment was in process in order to fill the current vacancies.

Medicines were administered safely by staff who had been assessed as competent. However, medicine room temperature checks sometimes went above the recommended storage temperatures. There were no documented temperature rechecks or actions taken to keep the room at a suitable temperature for medicine storage. This increased the risk medicines losing their effectiveness.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. Staff were aware of the Mental Capacity Act (MCA) and how this applied when delivering support to people.

Care plans were person centred, updated regularly and reflected wishes, goals and aspirations. They included life stories and people's current interests.

People told us they were treated with dignity and respect. They were happy about the food and told us they were supported to access health care services when required.

Activities were in place, however people thought they could be more varied and stimulating.

People and their relatives told us they were able to make a complaint. Complaints were investigated and actions taken were known by staff.

People and their relatives thought the acting manager was approachable and had made a few positive changes. However, there was no registered manager in place or deputy manager at the time of inspection. Although renovations were in progress the premises were still in places not maintained and posed a potential safety hazard.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 which can be found at the end of this report.

We carried out an unannounced focussed inspection on 7 July 2016. After that inspection we received concerns in relation to staff shortages, poor infection control practices and care not being delivered safely. As a result we undertook a comprehensive inspection on 17 August 2016 to look into those concerns. At the previous inspection in July 2015 the service was rated requires improvement under safe because improvements to medicines management and cleanliness were not yet sustained.

Romford Grange Care Home is registered to provide accommodation for 41 people

who require nursing or personal care. The home provides services to adults who have a physical disability, people with dementia care needs, older people who are physically frail and those in need of nursing care. On the days of our visit there were 38 people using the service.

There was a 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 service was not always well-led. Although a lot of progress had been made to implement changes and manage poor performance, there was still a divided culture with some staff resistant to change. We have made a recommendation about motivating staff and team building.

Quality monitoring systems were in place. However we identified shortfalls with the cleanliness, maintenance of premises and record keeping.

People were supported to eat but were not always supported to drink sufficient amounts. We have made a recommendation about hydration.

The premises and equipment were not always clean or well maintained.

Care plans included people’s preferences and involved people and their relatives as much as possible. We saw people participate in various activities such as doing puzzles, playing bingo and gardening. We noted that people in their rooms did not receive much stimulation compared with those who chose to stay in communal areas and recommend more effort is made to address this.

There were robust recruitment procedures in place in order to ensure that only people who had undergone the necessary checks were employed.

However we noted that people were supported by staff that were not always able to support them effectively. Which meant people sometimes received inappropriate care that did not meet their needs.

People told us that they were happy living at the home and that their wishes were respected. Staff were aware of the procedures in place to protect people from harm. They were able to demonstrate understanding of emergency procedures including fire and accident reporting.

Staff had attended relevant training and were aware of how to apply the Mental Capacity Act in their daily role. They were supported by means of regular supervision and annual appraisal. Staff meetings were held to enable them to share their views.

Medicines were managed safely. Any complaints made were acknowledged and responded to in accordance with the service’s policy.

We carried out an unannounced comprehensive inspection of this service on 19 November 2014. Several breaches of legal requirements were found. These related to medicine management, quality assurance and accurate record keeping. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches.

We undertook this focused inspection on 17 July 2015 to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Romford Grange Care Home on our website at www.cqc.org.uk.

Romford Grange Care Home is registered to provide accommodation for 41 people who require nursing or personal care. The home provides services to adults who have a physical disability, people with dementia care needs, older people who are physically frail and those in need of nursing care. On the day of our visit there were 38 people using the service.

Although there was a manager in place, at the time of our visit the manager was still in the process of completing registration with the Care Quality Commission. 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 told us that they were happy living at the service and that they felt safe and trusted the staff who cared for them. Medicines were managed safely. Measures had been put in place to ensure that all medicines were accounted for including those sometimes found on the floor.

We found improvements had been made to the cleanliness of communal bathrooms and the kitchen cooker. Replacement flooring was being completed in phases .There was evidence that work to secure the clinical waste was scheduled to take place soon after the inspection. We were sent confirmation receipts and photographs to confirm this had been completed soon after the inspection.

Regular meetings were held with people and their relatives in order to listen and respond to their views on issues such as activities, cleanliness and meals.

Care was assessed, planned and reviewed regularly. We observed that staff were aware of people’s needs and supported people in an appropriate manner as outlined in their individual care plan.

There were systems in place to monitor the quality of care provided, and obtain feedback from people who used the service. Team working between care staff and nurses and the accuracy of people’s records had improved and were now meeting legal requirements relating to maintaining accurate records of care.

We carried out an unannounced inspection on 19 November 2014. At our last inspection on 4 December 2013 the provider was found to be meeting the regulations we looked at.

Romford Grange Care Home is registered to provide accommodation for 41 people who require nursing or personal care. The home provides services to adults who have a physical disability, people with dementia care needs, older people who are physically frail and those in need of nursing care. On the day of our visit there were 37 people using the service.

Although there was a manager in place, at the time of our visit the manager was still in the process of completing registration with the Care Quality Commission. Following the inspection the manager completed registration.

‘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 told us that they were happy living at the home and that their wishes were respected. We observed staff speaking to people in a courteous manner. Regular meetings were held with people and their relatives in order to listen and respond to their views on issues such as meals, staffing, and activities.

People were safeguarded from harm and cared for by staff who were knowledgeable about how to recognise and report abuse. Medicines were stored and ordered appropriately. However, there were shortfalls in the handling and administration of medicines as staff sometimes found medicines on the floor and the provider had not taken action to address this. Care was assessed and planned and reviewed regularly. We observed that staff were visible and supported people in a polite and professional manner.

We found that people were supported to eat a balanced diet and had access to health care professionals as and when needed. There was choice of a cooked breakfast daily and sandwiches or salads were available if people did not like the meal.

There were systems in place to monitor the quality of care provided, and obtain feedback from people who used the service. However, staff felt that team working between care staff and nurses could be improved. We also saw shortfalls in the training related to Mental Capacity Act 2005 (MCA) specifically for care staff and the effectiveness of the infection control and medicines audits. We found at times that records maintained about the care delivered to people were inaccurate.

At this inspection we found that the provider was not meeting the legal requirements in relation to medicines management, maintaining accurate records of care and assessing and monitoring the quality of service provided. You can see what action we told the provider to take at the back of the full version of the report.

One person using the service told us “It’s very nice here. The staff are very good.” A relative of someone using the service said “It’s a wonderful home. The staff are very kind.”

Care plans were in place to help people maintain their health and safety. There were also procedures to ensure that people who were using the service were involved in their care and asked for their consent before they received any care or treatment. In cases where people were not able to make a decision about their own care because of capacity the provider adhered to relevant guidance on how to work in that person's best interest.

The provider had an effective system of audits which monitored the quality of the service and there were action plans in place for when any problems or improvements were identified.

People were provided with a choice of suitable and nutritious food and drink. There was a good range of food choices available and the options were clearly displayed. We observed that people who had difficulty with eating and drinking were supported by staff so that they could eat and drink sufficient amounts to meet their needs.

There were enough qualified, skilled and experienced staff to meet people’s needs. Staffing levels had recently increased in response to staff requests to have additional cover during the early evening period. Staff worked on a six-weekly rota and staff absences were adequately covered by the provision of 'bank' staff.

The majority of people were satisfied with the care they had received and found most of the staff to be friendly and helpful. One person told us, "It’s a nice place to live here, everyone is friendly". One person told us the staff on duty during the day were all helpful if you needed something, but that some of the night staff in particular were less helpful and could be abrupt.

People told us the home was always clean and tidy and that the food was good with a choice available.

People experienced care, treatment and support that met their needs and protected their rights. Overall people thought that the service had made a number of improvements since our last inspection in January 2013 which had raised a number of concerns. People told us “the carers are great, they come when I need them”.

The manager told us that she has had meetings with staff and relatives about the concerns raised over standards of care and to inform people about the plans for improvement. Relatives told us that things had changed for the better, one relative said “the difference now is there is someone to talk to about issues and she will do something about it”.

Care and treatment was planned and delivered in a way that was intended to ensure people’s safety and welfare. Risk assessments were in place and reviewed on a regular basis. This meant the risk of people receiving unsafe or inappropriate care was avoided.

People were cared for in a clean, hygienic environment. We looked at all the communal toilets and bathrooms at the location and found that they were all clean. We examined the sluice room and found it to be clean and tidy.

We spoke to the manager of the home who told us that an effective monitoring system had now been put in place to ensure that the home remained clean and properly maintained at all times. We examined the cleaning records that showed all rooms and equipment had been cleaned on a daily basis.