The Grange Nursing home provides care and accommodation for up to 23 people some of whom have are living with dementia. Accommodation is provided over two levels with lift access. There were 21 people living at the home at the time of the inspection.

We last inspected the care home in May 2016 and rated the service as requires improvement and identified a breach of the regulation relating to safe care and treatment. People who required support with moving and handling could not currently have a bath or shower because the bathroom was being modernised and adapted and fire instruction had not been carried out at regular intervals for night staff.

This comprehensive inspection took place on 11 July 2017 and was unannounced. Two further announced visits were carried out on 14 and 21 July 2017 to complete the inspection. At this inspection we found that action had been taken with regards to the breach and the provider was now meeting all the regulations we inspected against.

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 and associated Regulations about how the service is run. The provider’s main director was the nominated individual and oversaw the management of the service.

Prior to and during our inspection, we received information of concern relating to one person’s care and the management of the service. We took this information into account whilst planning and carrying out our inspection. Throughout this report, we state that people and the majority of relatives told us the service was safe, effective, caring, responsive and well led. This was due to the concerns we received which related to each key question. We checked the specific issues raised and examined other important sources of information outlined in the background section of this report to complete our inspection and support our judgements and ratings. The concerns raised in relation to this one person’s care are being dealt with outside of this inspection process.

We received mixed feedback from people, relatives and staff about whether there were sufficient staff deployed. We spent time observing the care which was provided in the late afternoon/early evening. This period of time was very rushed and several people had to wait for assistance. We have made a recommendation that the provider reviews staffing levels to ensure that staff are deployed to meet people’s needs in a timely manner.

We checked staff recruitment. We noted that two staff had a Disclosure and Barring Service [DBS] Adult First check in place. This had been obtained to ensure they were not barred from working with vulnerable people; however their full check with details of any possible cautions and convictions had not been received at the time of their employment. We noted that a risk assessment had not been completed with regards to this issue. The registered manager addressed this immediately.

Checks and tests had been undertaken to ensure that the premises were safe. Fire safety checks and instruction had been carried out. Action had been taken to ensure the environment was suitable for people with a dementia related condition. The main bathroom had been refurbished and fully adapted.

There were safeguarding procedures in place. Staff were knowledgeable about what action they should take if abuse was suspected. The local authority safeguarding team informed us there were no organisational safeguarding concerns regarding the service.

Medicines were managed safely. This included the management of controlled drugs which require stricter controls because they are liable to misuse.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the pol

The inspection took place on 26 May 2016 and was unannounced. This meant that the provider and staff did not know that we would be visiting.

The Grange Nursing Home provides care to a maximum of 23 older people, some of whom have a dementia related condition. There were 21 people living at the home at the time of the inspection.

We carried out a comprehension inspection in November and December 2015 where we found multiple breaches of the regulations. We rated the Grange Nursing Home as 'Inadequate' and placed the service in 'Special measures.' Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

After the comprehensive inspection, the provider wrote to us to say what action they were taking to meet legal requirements.

We inspected the service again on 26 May 2016 to check that action had been taken. We found that significant improvements had been made in many areas of the service, although further action was required regarding the premises, documentation relating to the Mental Capacity Act 2005 and care planning. In addition, we had not been notified in a timely manner of one person’s injury which had required hospital treatment.

The previous registered manager had left the service. There was a new manager in post who commenced employment in February 2016. He was not yet registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the CQC 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.

People who required support with moving and handling could not currently have a bath or shower because the bathroom was being modernised and adapted. Fire instruction had not been carried out at regular intervals for night staff.

We checked medicines management. Staff were currently administering medicines from their original packaging. The manager told us that because of some minor omissions and anomalies he had requested that their pharmacy supplier provide medicines in a monitored dosage system. He explained that this would highlight any errors in a timelier manner.

There were safeguarding procedures in place. Staff knew what action to take if abuse was suspected. They were fully aware of the whistle blowing procedure. External whistle blowing training had been booked in June 2016.

Safe recruitment procedures were followed. We found gaps in the employment history for one staff member. The manager was able to give us an explanation for the gaps and told us that this information would be added to the staff member’s interview record. No concerns about staffing levels were raised by people or relatives. We observed that staff carried out their duties in a calm unhurried manner.

The manager provided us with information which showed that staff had completed training in safe working practices and to meet the specific needs of people who lived there, including dementia care and Parkinson’s disease training.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS) and to report on what we find. MCA is a law that protects and supports people who do not have ability to make their own decisions and to ensure decisions are made in their ‘best interests’ it also ensures unlawful restrictions are not placed on people in care homes and hospitals. 18 applications had been submitted to the local authority to authorise in line with legal requirements. The manager told us that these had not been autho

Prior to our inspection, we received information of concern about a serious incident which had occurred at the home. We took this information into account when planning our inspection.

We commenced our inspection on 27 November 2015. The inspection was unannounced which meant that staff and the provider did not know that we would be visiting. We visited the service out of hours at 6.30pm on the first day of our inspection. We carried out three further visits to the home on 3, 4 and 7 December 2015 to complete the inspection.

The home was last inspected in March 2015. We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to consent to care and treatment; management of medicines; safety and suitability of premises and assessing and monitoring the quality of service provision. The provider submitted an action plan which stated what action they were going to take to improve in these areas. They stated that the actions and improvements would be completed by July 2015.

At this inspection, we found that the registered provider had not followed their plan and legal requirements had not been met.

The Grange Nursing Home is situated in Warkworth, Northumberland and provides accommodation for up to 23 older people who require nursing or personal care. There were 22 people living at the home at the time of our inspection.

There was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

Some staff raised concerns about how a recent incident had been dealt with. The manager confirmed that the correct procedures had not been followed and she had not notified the person’s care manager or ourselves. We are investigating this incident and will report on any action once it is complete.

Following our inspection, the local authority’s safeguarding adults team carried out their own investigation into this incident. Allegations of neglect against the registered manager were upheld.

We found that systems to protect people from the risk of abuse were not fully in place. We had not been notified of one safeguarding incident. We found the provider had not taken appropriate action to fully protect people following the recent incident.

We checked the premises and saw that some of the window restrictors which had been fitted to upstairs windows did not conform to the Health and Safety Executive (HSE) design guidelines. These could be overridden and the windows opened fully. Following our inspection, the provider informed us that this had been actioned.

The adaptation, design and decoration of the premises did not fully meet the needs of people who lived with dementia.

There were no designated sluice facilities and staff were manually washing continence equipment in an unused bathroom on the first floor. This procedure increased the risk of cross infection.

Nine of the 13 people who used bed safety rails to reduce the risk of them falling out of bed did not have any bed rail bumpers fitted [protective padding]. This omission meant that people were not fully protected from the risk of injury.

Staff told us that prior to our visit they transferred some people to the shower room using shower chairs. It was not clear whether the shower chairs were designed for the transportation of people around the home. One shower chair had been disposed of following the serious incident and the other shower chair had been stored in the loft. The maintenance man told us that checks had not been carried out to ensure the safety of the shower chairs. This meant that equipment used in people’s care had not always been assessed as being appropriate or safe.

There were shortfalls in the man

People told us that they liked living at the Grange. We spoke with four people living in the home and one relative who was visiting. People living in the home said that staff encouraged them to make choices about their care, treatment and support. One person said that she knew she had a care plan and that she had been asked if she was happy with the content of it. People said they enjoyed the food at the home. They said that there was always plenty of well cooked food. One person said “everything is home made and I really enjoy the meals.” People said that they had a choice of what to eat and where to take their meals. People said that staff were kind and helpful. They said staff responded promptly to any requests and that they felt there were enough staff. The relative of one person said she was very satisfied with the care and support provided. She said staff made sure she was informed if there were any changes in her mother’s condition. She said staff were always cheerful and kind. People told us that they felt safe at the home and they were able to voice their opinions and concerns.

The inspection took place on 10 March 2015 and was unannounced. We carried out a second visit to the service announced on12 March 2015 to complete the inspection.

The service was last inspected on 13 August 2013. We found they were meeting all the regulations we inspected at that time.

The Grange Nursing Home accommodates up to 23 older people, some of whom have dementia related conditions. There were 21 people living at the service at the time of the inspection.

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 and associated Regulations about how the service is run.

Although the provider remained the same; there had been a change in directors which meant that a new management structure was in place. The previous director had sold the business three weeks prior to our inspection and there were two new directors in place. The registered manager explained there had been some uncertainty amongst staff over the past year because of the proposed sale. She told us and staff confirmed that morale had improved following the sale to the new directors.

There were safeguarding procedures in place. Staff knew what action to take if abuse was suspected.

We had concerns with certain areas of the premises. Window restrictors were not fitted to windows; concerns had been highlighted on the electrical installations report which had not all been addressed and there were no designated facilities for the cleaning and disinfection of continence equipment.

Following our inspection, the registered manager immediately wrote to us with an action plan outlining the areas of concern we had found and how they were going to address them.

We passed these concerns to the local authority contracts and commissioning team and fire safety team.

We found the design and decoration of the premises did not always meet the needs of people who had a dementia related condition. We have made a recommendation that the design and decoration of the premises is based on current best practice in relation to the specialist needs of people living with dementia.

We found some concerns with medicines management. The controlled drugs cabinet did not meet with legal requirements to ensure the safe storage of controlled drugs. We also found staff were not always making a record of any medicines which were disposed of. Following our inspection, the registered manager told us that she had ordered and fitted a new controlled drugs cabinet within 48 hours.

People, relatives and staff told us there were sufficient staff employed at the service to meet people’s needs. Staff told us training courses were available in safe working practices and to meet the specific needs of people, such as those living with dementia.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS). DoLS are part of the Mental Capacity Act 2005 (MCA). These safeguards aim to make sure people are looked after in a way that does not inappropriately restrict their freedom. We found however, that there had been a delay in ensuring people were only deprived of their liberty in a safe and correct way, which was authorised by the local authority, in line with legislation. In addition, people’s care plans did not always show that care planning was carried out following the principles of the MCA.

People were complimentary about the meals at the home. We observed that staff supported people with their dietary requirements.

People and relatives told us staff were caring. Staff who worked at the service were knowledgeable about people’s needs. Most of the interactions we observed between people and staff were positive.

An activities coordinator was employed to meet the social needs of people. People spoke positively about the activities and events which were organised.

There was a complaints procedure in place and people and their relatives knew how to complain if they needed to. The registered manager told us that no complaints had been received.

We found there were a limited number of audits to monitor the quality of care. We considered that the lack of auditing meant the provider was not able to demonstrate that quality standards and improvement actions were being identified, implemented and sustained.

We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. These related to consent to care and treatment; management of medicines; safety and suitability of premises and assessing and monitoring the quality of service provision. These corresponded with four breaches of the new Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to premises and equipment; safe care and treatment in relation to medicines; consent and good governance. You can see what action we told the provider to take at the back of the full version of the report.