The inspection was carried out on 9 May 2017 and was unannounced. The service is a residential care home that can accommodate up to 29 older people; some people may also have mild dementia type illnesses that they have developed whilst resident. At the time of inspection there were 22 people in residence. People have their own bedrooms; some have ensuites; bedrooms are located over the ground and first floors. A shaft lift provides access to the first floor.

There was a registered manager in post. A registered manager is a person who is 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 the previous inspection in May 2016, we found that the provider was not meeting all the regulations inspected at that time because the quality monitoring system in place were not effective. Medicines administration and recording needed improvement as did the recording of fire drills, and tests of fire equipment. The service at that time had also not ensured that The Care Quality Commission was informed of notifiable events.

Staff spoke kindly to people and treated them with respect. People were able to make decisions and choices for themselves about what they did, and where they ate their meals and with whom, people were encouraged where possible to maintain their independence seeking support when needed.

At this inspection we looked at the improvements made in these areas and was satisfied these had been addressed appropriately. The provider, who was a visible presence in the service, had taken steps to ensure greater involvement in the day to day operation of the service. This helped to relieve the registered manager of some responsibilities in regard to the completion of paperwork meaning they could increase their focus on care delivery. Investment in an electronic records system provided the facility for the registered manager and the registered provider to have greater oversight and scrutiny of day to day care delivery, even remotely when not on site. This enabled the registered manager and provider to check at any time of day or night, the support provided to people, the administration of their medicines, food and fluid intake, personal care routines supported and activities participated in. This provided them with greater assurance that all aspects of the service were meeting requirements consistently and systems in place were being carried out as per their own policies and procedures.

More robust recruitment practice meant that staff suitability for the role was assessed through a full range of checks in line with legislation requirements. Medicines were managed well and observed staff practice showed improvements in the way administration was undertaken and recorded. Staff understood how to keep people safe from abuse and harm. In the event of a fire or event requiring evacuation staff had had practiced for this and the registered manager ensured all staff attended a minimum of two practice drills per year. Staff understood where to take people to keep them safe. The premises were well maintained. All areas viewed were visibly clean and cleaning staff told us about their cleaning schedules each day. All necessary equipment servicing, checks and tests were carried out. The Provider also carried out an annual health and safety check to ensure that the environment was safe and that equipment was in good working order.

The majority of individual and environmental risks to people’s safety were assessed and managed appropriately. There was a low level of incidents and accidents and staff took appropriate action when these occurred, the registered provider and registered manager understood what events they needed to notify the Care Quality Commission about.

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The inspection was unannounced and took place on 18 & 19 May 2016. The Grange is a care home which provides care and support for up to 29 older people. There were 26 people living at the service at the time of our inspection. People cared for were all older people; some of whom were living with dementia . People have their own bedrooms; some have ensuites; bedrooms are located over the ground and first floors. A shaft lift provides access to the first floor.

This service was last inspected on 29 August 2014 under previous methodology and at that time the provider was found to be compliant and no breaches of regulations were identified.

There was a registered manager in post. A registered manager is a person who is 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 were happy living at the service, their relatives also spoke positively about the quality and delivery of care provided to their family members. Professionals we spoke with during and after the inspection spoke positively about the good working relationships the staff fostered with professionals, and the quality of care they provided to people.

Systems that the service had in place to protect the safety and wellbeing of the service users not always being followed; this could place people at risk. The lack of a comprehensive quality monitoring system meant the provider and registered manager could not be assured that all aspects of the service were meeting people’s needs..

Recruitment procedures and checks of new staff were made but this needed improvement to ensure these were carried out thoroughly and in line with regulatory requirements. The management of medicines ordering, receipt, disposal and administration was managed well and people received their medicines in a personalised manner that took account of their preferences; improvement however, was needed to the way in which medicines administration and changes to medicine records were made. Fire alarm and emergency lighting tests were not conducted in accordance with the homes fire risk assessment and although staff said they attended fire drills, there was no evidence for this to ensure they understood how to respond in the event of a fire.

The service had not consistently notified the Care Quality Commission about people who had experienced a serious injury that required hospital treatment as required by regulation. The risk assessment framework used needed expanding to ensure all potential risks people may be subject to were assessed and measures implemented to reduce risk of harm occurring.

Staff treated people respectfully, showed kindness and patience and we saw many examples of positive interactions from staff towards people. Staff placed people at the centre of the support they provided and delivered this in a personalised way to meet individual needs.

People and their relatives told us they felt informed by the staff and that communication was good. They were asked for their views and people felt able to voice their comments openly in user meetings. People ate a varied diet, specialist diets were catered for and people were able to request alternatives to the menu if they wanted to.

The premises provided a pleasant comfortable clean and well maintained environment and people appreciated and valued the lovely grounds and the period appearance of the premises. Staff understood how to keep people safe from harm. There were enough staff to meet people’s needs. New staff received appropriate induction and all staff completed a regular programme of training. Staff understood and worked to the principles of the Mental Capacity Act 2005.

People enjoyed the activities provided for them and were consulted through meetings and questionnaire

The inspection was carried out by one Inspector over five and a half hours. During the visit we talked with ten people living in the home, some individually, and others together in one of the lounges. We also met other people briefly, and observed staff carrying out care duties. The manager was available during the day, and we also met and talked with the three providers. They worked together as a family run business. We talked with five other staff, and two visitors. The staff team included a deputy manager and a head of care, but they were not available due to annual leave.

We looked at the answers to five questions: Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

Is the service safe?

We saw that the home was visibly clean in all areas and was well maintained. The premises included spacious gardens which were attractively presented. There were reliable procedures in place to manage on-going maintenance.

We inspected medicines management and found that suitable procedures were in place to ensure that people received the right medicines at the right time, with the support of appropriately trained staff.

We found that the management staff had procedures in place to ensure that people consented to the care and support provided for them. None of the people in the home lacked the mental capacity to make day to day decisions, and most were able to make complex decisions. One of the providers and the manager showed us that they understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS), to apply for DoLS if this was indicated. This would apply to people who might be assessed as needing their liberty restricted for their own safety. We saw that people’s next of kin or authorised representative were included in complex decision-making and consent procedures where people living in the home had delegated this to them.

Is the service effective?

We saw from looking at care planning that people were assessed prior to their admission to ensure that the home would be able to meet their assessed needs. This included people having sufficient mobility to move around without the need for hoisting facilities and wheelchairs within the home, as the premises were not suitable for using this sort of equipment. However, the premises did include two lifts to all floors, and assisted bathing facilities.

We found that care plans contained clear information which enabled staff to provide effective care. The care plans were reviewed monthly, and were updated prior to this if people’s needs changed.

The home provided people with a variety of food and drinks to meet their different nutritional needs. People said that the food was very good, and they had “more than enough”.

Staff had been trained in required subjects such as health and safety, moving and handling, infection control and fire safety. We saw that this training was kept up to date. Other relevant training courses were provided so that staff could develop their knowledge in line with the needs of people living in the service, such as training in diabetes.

Is the service caring?

The home was a family run business and this was reflected in the care given by the staff, in that people living in the home said “It feels like a big family here”. All of the people that we spoke to were very positive about the home’s relaxed atmosphere and the kindness of the staff. People’s comments included, “Everyone is so kind, it is lovely here”; and “It is excellent here. It is a home from home, and the staff are wonderful.” We saw that recent questionnaires also included very positive responses, with remarks such as “The girls (i.e. care staff) are very good; the Grange is very good indeed.”

We saw that staff took time to chat with people, and assisted them to sit where they wanted to. They ensured that people had the things they needed next to them, such as a drink, their handbag and a call bell pendant if they required this. The pendants enabled people to call for staff from anywhere within the building.

The home enabled people to carry out their choice of daily activities, with newspapers, books and televisions available. A range of shared activities was provided during the week for those who wished to join in with these.

Is the service responsive?

The home had an arrangement with a local GP surgery for weekly visits to the home. Most people chose to be registered with this practice. This enabled people to see their doctor as needed.

The staff had systems in place to monitor people’s general health, so that staff were aware more quickly if people might be unwell or need medical advice. People were referred to other health care professionals as needed for further advice, such as dieticians, opticians, community nurses and dentists.

People said that if they had any concerns they would ask to speak to the manager. They were confident that she would investigate any concerns thoroughly and would take action to deal with anything needed. People spoke highly of other staff too, and two people said “I would ask the care staff for most things, and then the manager if I needed to.” The manager and one of the providers oversaw the day to day running of the home, and spoke to most people each weekday to see if they were happy with how the home was being run.

Is the service well-led?

We saw that people in the home knew the manager and providers well, and had confidence in them to deal with any issues.

Staff said that they had daily handovers, and changes were discussed during these times. They used a communication diary to record any day to day changes to ensure things were not missed. Staff meetings were held to enable staff to discuss relevant issues and raise new ideas. The manager carried out individual supervision with staff every two to three months; and yearly appraisals were completed. This provided staff with the opportunities to discuss individual training needs, and to develop within their different roles.

People living in the home saw the manager or one of the providers nearly every day, so they could easily raise any issues or concerns. We saw that residents’ meetings were held so that people could discuss things together. People’s views were also obtained through twice yearly questionnaires. The results of these were analysed, and action was carried out to respond to any identified changes.

The home had monitoring procedures in place. This included regular checks for maintenance and safety, such as checking water temperatures, checking the nurse call bell system, and checking fire alarms and fire equipment.

We spoke with seven people who used the service, six relatives, four staff and the manager of the service. People told us they were treated with dignity and respect. One person said staff were "Kind and respectful" and other person told us the "Staff are respectful and they make me laugh".

People said they were involved in decisions about their care and treatment. One person told us that staff "Value people's views and decisions".

We found that people were involved in their care planning and that their care plans had regular monthly reviews. This meant that people's care plans were updated as their needs had changed and therefore, their care was tailored to their current needs.

People told us they felt safe at the service and their personal belongings were looked after. One person told us they had a "Lockable draw to put things in...but there were no problems...everything was very safe". People were confident in talking to their key worker, staff or the manager if they had any concerns and felt the service would deal with any concerns promptly.

Staff told us there were enough staff to provide safe and effective care. A member of staff said "There is a good skill mix" and that they had no concerns regarding the skill base. They said "Everyone works as a team".

People and their relatives were invited to express their views and opinions by talking to the manager and staff, through "a suggestion box and resident meetings" and on their visits to the service.

During the inspection visit we spoke with five people who used the service and a visitor. People told us they were treated with dignity and respect by staff. We observed that people had personalised their rooms with their own belongings. Individual choice was respected for example in regard to people being able to have meals in their rooms and their preferences in social activity. One person told us "It was their choice" to decide waking and bedtimes and whether they had their breakfast in their room.

People told us they were involved in the planning of their care and were able to speak to their key worker or manager if they wanted changes in the support being provided or had any concerns about their care. People said they felt safe in the service and that their personal property was respected.

The service was clean and tidy. People felt they lived "Very comfortably" in the service and "Enjoyed a good lifestyle". They told us they talked to the staff about any problems they had and actions had been taken to address any issues they had.

People told us staff had talked to them about the care and support they needed when they first came to live at The Grange. Some people told us the manager had visited them prior to them moving in to discuss their needs. Most people and relatives spoken with did know about their care plan, felt they had been involved in reviewing it and that they had signed it in agreement.

People told us they were able to make decisions about their care and day to day lives. That their care and support they required was discussed with them when they first began to use the service and when any new concerns about their care arose. People said that they had discussed their support and preferred routines with staff and they had the help they required and independence was encouraged. One person said she was happy that staff supports her with her needs.

Relatives said that they were kept well informed about their relative when there had been concerns. One relative said that they felt the home offered an inclusive family atmosphere and that the manager was receptive to their comments and suggestions.

People told us they were happy with the food and liked the meals. Comments included “it is good, nicely prepared and fresh”. “It’s nice”. “It’s very good”.

People told us the staff came round each day and asked their preferences.

People told us they felt safe living at The Grange. They had the opportunity to raise concerns and were empowered to make any complaint where they had concerns. They said that communication with management was excellent and that the staff were aware of how to protect people who use the service from abuse.

People told us staff was to hand when they needed them and came when they rang their buzzers and that the home was always clean and tidy.

People told us the staff was all very kind and caring