What life is like for people using this service:

• Every person we spoke with fed back that staff were caring and they were happy living in the service. Relatives told us the service felt like a home and they were made to feel welcome when they visited their loved ones.

• Bedrooms were personalised and people had their photographs on display, there was the smell of home cooked food and baking throughout the building. Some building improvements needed to be made to modernise the facilities but the provider had already planned these.

• Staff felt supported and had received enough training to enable them to support people in line with best practise guidance. Staff told us they enjoyed their jobs and had a good understanding of person centred care.

• People were offered choices in their day, the registered manager had good knowledge of the Mental Capacity Act 2005 (MCA).

• There had been several improvements introduced since our last inspection. Records were more accurate and contained more detailed risk information for specific health conditions.

• The quality of the care was regularly audited and care improved as a result. Issues were followed up with staff and relatives and people were encouraged to feed back to the registered manager.

• People’s health needs were met with referrals to health professionals where needed. Regular contact was had with the district nurse and GP, both of whom gave positive feedback about the service.

• Medicines were managed safely and administered calmly. Recording was accurate.

• Activities were daily and offered a range of different things to do but these were not always to people’s tastes. Improvements to the activities offered were underway at the time of our inspection.

More information is available in the detailed findings sections below.

Rating at last inspection: Requires Improvement (report published 23 November 2017)

About the service: The Grange Residential Hotel (hereafter referred to as The Grange or the service) is a residential care home that was providing personal and nursing care to 14 people aged 65 and over at the time of the inspection. The service is in an adapted period property in the village of Ipplepen in Devon.

Why we inspected: This was a planned inspection based on the last rating. This service is a service that has been rated requires improvement in two out of three previous inspections.

We carried out this inspection of The Grange Residential Hotel on 24 and 28 July. The first day was unannounced. The Grange Residential Hotel is a care home which is registered to provide care for up to 17 people. Most of the people living at the home were older people. The home also provides staff to care for people in their own homes, or in an adjoining supported living service. A supported living service is one where people live independently but have access to care support should they require assistance. The home does not provide nursing care; this is provided by the community nursing team.

At the time of this inspection 15 people were living at the home and seven people were living in the supported living service, although none of these people were receiving support with their personal care needs. As CQC is only responsible for looking at personal care delivered at the supported living service, we did not inspect that service on this occasion.

At the time of our inspection the home had a registered manager. However, the registered manager was on maternity leave. We were supported during the inspection by the deputy manager and a registered manager from one of the registered provider’s other care homes. 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.

In September 2016 we carried out an unannounced comprehensive inspection of this home. The home was rated as ‘good’ overall with ‘requires improvement’ in the key question ‘Is this service safe?’ In July 2017 we received concerns in relation to how risks to people were being managed, the management of accidents and incidents at the home, staffing levels and the leadership of the home. There were concerns that people's charts, for example, food and fluid charts, falls records and accidents and incident forms, were not being recorded correctly.

We initially undertook a focused inspection on 24 July 2017 to look into those concerns but changed this to a comprehensive inspection.

People's feedback about the home and the management of the home was positive. People said the deputy manager and registered manager were approachable and had confidence in their ability to manage the home. We found that governance systems to monitor the care quality and safety at the home had not always been effective. We identified a number of areas that required improvement.

Some risks associated with people’s particular health needs had not always identified or mitigated. Care plans and risk assessments were not always updated when people's needs changed. This meant that staff could not ensure they were managing people's needs and risks effectively. People’s care records did not always contain sufficient guidance for staff to minimise risks to people.

People received their medicines safely and as prescribed. Records relating to some topical medicines were not always up to date. The room where medicines were stored was hot during the days of inspection. Staff took immediate action to address this. Staff received training and their competence had been assessed.

We made a recommendation to the provider about their medicine auditing and monitoring processes.

Records we looked at showed that people did not always have assessments of capacity in place where required and the outcomes of any best interests decisions made on their behalf were not always documented. We saw that staff had not completed training in regards to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). However, staff sought people's consent before they assisted them with their care needs. We saw staff took time to explain to people what they were doing and people were involved in everyday decisions about their care.

We made a recommenda

We carried out this unannounced inspection of The Grange Residential Hotel on 29 September and 3 October 2016.The Grange Residential Hotel is a care home which is registered to provide care for up to 17 people. The home is arranged on two floors and situated in the small Devon town of Ipplepen. The service also provides staff to care for people in their own homes, or in an adjoining supported living house. A supported living service is one where people live independently but have access to care support should they require assistance. The service does not provide nursing care; this is provided by the community nursing team.

At the time of this inspection 14 people were living at the home and eight people were living in the supported living service, although none of these people were receiving support with their personal care needs.

The home had a registered manger 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.’

During the previous inspection in April 2015 we found there were breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We identified improvements were required in relation to care and medicine records, manual handling practices, staff’s’ understanding of the Mental Capacity Act (2005) and deprivation of liberty safeguards and staff training. At this inspection in September and October 2016 we found improvements had been made. However the documentation relating to the application of people’s topical medicines and how people were supported to use the home’s facilities safely required improvement.

While records showed people received their oral medicines as prescribed, those relating to the application of topical creams were incomplete. Where people had been prescribed creams to be applied more than once a day, these had only been recorded once, and where more than one cream was prescribed it was not possible to identify what cream had been applied at what time. The registered manager said they would remind staff of their responsibility to ensure people received these as prescribed and that records were fully completed.

Following the previous inspection, care practices in relation to assisting people with their mobility had been addressed and we saw staff assisting people and using equipment safely. However, where staff were assisting people to use the ground floor toilet facilities, we saw this posed a risk to people who required assistance to stand due to the small size of the room. We asked the registered manager to consider how people could be assisted more safely and they instructed staff to use either people’s en-suite facilities or the toilet on the first floor which was large enough for people’s wheelchairs.

Staff were knowledgeable about the people they supported and told us about people’s preferences. Care plans had been reviewed since the previous inspection. However, these were lengthy documents with information about each care topic recorded in different sections of the care files. We discussed this with the registered manager and by the second day of the inspection they had made changes to ensure the care files were more concise and easier to read. People were involved in contributing to their care plans and monthly reviews allowed people to comment about how they were being supported. Assessments of people’s capacity to make decisions about their care and treatment, or if a best interest decision needed to be made on their behalf, had been undertaken. However, while the assessments identified the decisions people were able or not able to make, the outcomes of the best interest decisions were not always documented in full. The registered manager confirmed they would ensu

People were very happy with the care and support they received and said they felt in control of their care. One person said “I have no complaints” and another said “It’s my home dear, I can do as I wish.”

Systems were in place to support people and involve family members where people were not able to make decisions or give consent to care

We found that people's needs were met in a respectful and discreet manner and according to their preferences.

We saw that well written accurate care plans contained details of people's physical and mental needs. Directions for care workers on how to meet these needs were easy to follow. We saw these needs had been met.

The home was well maintained, clean and tidy. There were systems in place to prevent the spread of infection.

People were very complimentary about the stable group of care workers and described staff as “wonderful”, “lovely” and “very kind.” There were effective recruitment procedures in place and staff had received sufficient training, support and supervision.

The home was well managed. People, staff and visitors all spoke highly of the manager and provider.

There were effective systems in place to regularly assess and monitor the quality of the services provided. There were also well structured processes to identify and manage risks relating to the health and safety at the home.

People told us they were happy at the home. One person said “I couldn’t fault it. The girls (care workers) are wonderful, my room is super, the care is good and the food is excellent”. Another person said “I have no worries at all.” Feedback from healthcare professionals and relatives was also very good.

We found that people's needs were met in a respectful and discreet manner. Care workers were able to tell us how they supported people and respected people’s preferences even though they could change.

We saw that well written accurate care plans contained details of people's physical and mental needs. Directions for care workers on how to meet these needs were easy to follow. We saw these needs had been met. Medicines were well managed at the home and were securely stored.

People told us they felt safe at the home and care workers were aware of the procedures to be followed if they suspected abuse was occurring.

People were very complimentary about the stable group of care workers. One person said “They are all lovely.”

We found that there were enough care workers on duty to meet the needs of the people who lived at the home. These staff had received sufficient training, support and supervision.

The home was well managed. People, staff and visitors all spoke highly of the manager and provider. Records reflected the management of the home. They were well maintained and securely stored.

We (The Care Quality Commission) carried out an unannounced visit to The Grange Residential Hotel on Monday 12 March 2012. We looked at both of the regulated activities the provider operated from the location. These comprised accommodation for persons needing nursing or personal care (i.e. a care home without nursing), and the activity of personal care, which was a domiciliary care agency. The domiciliary care service was providing care and support to people living in North Grange, which is described as supported living accommodation. North Grange is within the grounds of The Grange.

On the day we visited there were 16 people living at the home. The service was also providing personal care to eight people living in North Grange.

We met with most of the people using the services. We spoke in depth with six people about their experience of living at The Grange and using the services within North Grange. We also spoke with a relative, two visiting health professionals, four care staff, the manager and a senior manager. As well as speaking with people, we observed the care delivered to people.

People told us they were happy living at the home. They said they were treated well, routines were flexible and they had no concerns. One person told us, “The staff are marvellous”. Another said “Things couldn’t be better”. Other comments included, “I couldn’t wish for anything better”, “I can’t grumble at all”, “We are all friends here. There’s a friendly atmosphere. I have no complaints” and “The staff are dedicated”. People told us the staff were respectful, kind and friendly. The food was enjoyed by all and people were happy with the activities offered at the home. People told us the home was always clean and smelling fresh. This was echoed by one visitor and two health professionals.

People receiving personal care within the supported living unit (North Grange) told us they were satisfied with the care and support they received. One person told us, “The staff are lovely. They can’t do enough for you”. Another person told us how the staff were helping them to regain their independence following a recent illness.

The staff we spoke with told us that they were well supported. They said that they had a good range of information and training to help them care for people living at the home.

This inspection took place on 27 and 28 April 2015 and the first day of the inspection was unannounced.

The Grange Residential Hotel is a care home which is registered to provide care for up to 17 people. The home is arranged on two floors and situated in the small Devon town of Ipplepen. The service also provides staff to care for people in their own homes, or in an adjoining supportive living house. The service does not provide nursing care. The care workers access the community nursing service for this.

At the time of this inspection the registered manager was on maternity leave but was in contact with the home regularly. 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.

A senior member of staff had the responsibility for managing the home on a day to day basis, supported by the registered provider and a registered manager from one of the registered provider’s other homes.

We found some inconsistencies in people’s care records. Some held out of date information, or at times conflicting guidance for staff. Changes identified at reviews were not always transferred onto the care plan. This meant information about people’s current care needs and guidance for staff was not easy to access.

Records of people’s fluid intake were not always accurate and it was not possible to assess if people were receiving enough to drink to maintain their health.

Senior care staff had received training in the Mental Capacity Act 2005 (MCA). However, we found one person's capacity to make a decision about their future care and treatment had not been assessed in line with the MCA principles.

People’s liberty was being restricted to maintain their safety by the use of locked external doors. However, authorisation from the local authority’s Deprivation of Liberty Safeguards team had not been sought for those people who were not able to consent to their use: this was addressed immediately following the inspection. 

Some staff felt the home was short staffed and they were unable to fully meet people’s care needs. They said they were unable to provide sufficient supervision of people who were at risk of falling or spend time with people in conversation or individual activities. The registered provider confirmed staffing levels were reviewed in line with people's care needs, and the local authority's guidance. We saw people's care needs were met in an unhurried and timely way.

Staff had received training in topics relating to the care and safety of people such as moving and handling, safe medication practices and dementia care. Records were available of staff being assessed for their safety and competence in medication administration. Changes to medicine prescriptions were not always accurately recorded on to medicine administration records. Medicines were stored and administered safely.

We saw pleasant interactions between people and staff, and staff provided kindly reassurance to people who were unsure of what was happening due to their memory loss.

People who were able to share their experiences with us told us they felt well cared for and people seemed cheerful. They said The Grange was homely, they could get drinks and snacks whenever they liked and they enjoyed social activities at the home. We saw people enjoying games with staff and singing along to a musical film. Care plans held information about people’s preferred routines and staff were knowledgeable about these.

People had access to health care professionals such as GPs and the Community Nursing team.

Staff said concerns and complaints were dealt with as soon as possible and visitors told us they had no concerns, but had confidence in raising issues with the staff and registered manager.

We found a number of breaches of regulations and you can see what action we told the provider to take at the back of the full version of the report.