Windermere Grange Care Home

Windermere Grange Care Home is a residential care home. The service accommodates up to 64 people over two floors divided into four units. Two units provide care and support to older people, some of whom are living with dementia. People living with a learning disability are supported in the other two units. At the time of inspection 62 people were using the service.

People’s experience of the service and what we found:

Care plans provided guidance to ensure people received safe and responsive care and support. Risks were assessed and mitigated to keep people safe. However, where people may display distressed behaviours, the care plans we reviewed for older people lacked detail on what behaviours may be displayed and how these can be managed. Care plans were in place and contained person-centred information for people with a learning disability. However, care plans had not always been fully updated when changes occurred. Information in relation to people’s goals or outcome was not always clearly recorded. Daily records were generic and didn’t reflect the care needs identified in people’s care plans or the care provided. We spoke with the registered manager and Director of Care and Development about this. They assured us that the new electronic system they were introducing would address this.

Medicines were managed safely. Handwritten medicine administration records were not checked thoroughly, or counter signed to ensure accuracy; this is not in line with national guidance. Staff received training in medicines administration and competency assessments had been completed. Audit processes were in place, however work was needed to ensure the correct audit was completed at the right time and they were reviewed appropriately. We have made a recommendation about this.

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessment and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Right Support

People received care and support from staff who knew them well. People were supported to maintain and improve their independence. Risks in relation to people’s care and support were well managed to assist people to live their lives as they chose, and to access opportunities. There were enough staff to meet people’s identified hours of support, and this supported people to be able to access activities both socially and within their home.

Right Care

People received care and support from a staff team who knew their needs. One relative told us, “From what I can see they get the best care. She can call for assistance when she needs it.” The service worked with health and social care professionals to ensure they met people’s needs. A health care professional told us, “Staff know the residents really well. We come here knowing what issues there are and we always have a staff member accompany us during our visit. They follow up any guidance we put in place.”

Right Culture

People lived inclusive lives and were supported to take part in meaningful activities within the home and their local communities. One relative told us, “There are loads of activities going on. They do themed nights, and there are special foods from that country.” People and their relatives spoke positively about the service. Comments included, “I think the home is run well. The staff are always busy but still have time if you need to speak to them.”

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

There was a positive culture within the service. Staff felt supported by the management team. Their comments included that the management team were visible and approachable, and they could discuss concerns and share ideas.

The service worked in partnership with other social and health care professionals. Feedback from health professionals was positive and included the following comments: “Out of all the care homes we deal with, it is very organised. We come here knowing what the issues are. They send a list of who needs seeing on the day. All information is accurate. They are not resistant to change or our service input. They will follow up any guidance we put in place.”

Systems were in place to monitor the quality of the service. However, there are some improvements required with the oversight of accidents and incidents. The registered manager understood their responsibility to follow the duty of candour and to be honest and open when something went wrong.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was Good (Published 24 February 2020).

Why we inspected

The inspection was prompted in part due to concerns received about care planning, recording of accidents and incidents and staffing. A decision was made for us to inspect and examine those risks. We found no evidence during this inspection that people were at risk of harm from this concern.

We undertook a focused inspection to review the key questions of safe, responsive and well-led only. For those key question not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

You can read the report from our last comprehensive inspection by selecting the ‘All inspection reports and timeline’ link for Windermere Grange Care Home on our website at www.cqc.org.uk.

Recommendations

We have made a recommendation about the recording of some medicines. We have made a second recommendation about the provider ensuring care plans and daily records reflect the care needs for each person using the service.

Follow Up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right Support, Right Care, Right Culture is the guidance CQC follows to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

The service was able to demonstrate how they were meeting the underpinning principles of Right Support, Right Care, Right Culture. The registered manager had adapted how the service operated during the pandemic. Staff ensured they continually maximised people’s choice, control and independence in a safe and inclusive environment whilst also following national infection prevention and control guidance. Each person had their own individual, person centred COVID-19 care plan and risk assessment which promoted their rights, privacy and dignity.

We found the following examples of good practice.

Managers, staff and people living at the service had worked together to ensure the service remained an enjoyable and empowering experience for everyone. People were involved in all aspects of the service including discussions around COVID-19 safe activities and making the environment safe for everyone.

Systems were in place to prevent people, staff and visitors from catching and spreading infections. The service had adapted how to support people, as far as possible, with social distancing.

Staff had undertaken training in putting on and taking off PPE, hand hygiene and other Covid-19 related training. Infection control lead staff were in place who monitored staff practices and provided training to ensure the national guidance was being followed. The provider continuously shared important information about COVID-19 to staff.

The home was following national guidance for people moving into the home. Staff worked with people and their relatives to ensure they were aware of isolation procedures and the requirement of staff wearing PPE. People were supported by a dedicated staff team who ensured any feelings of isolation and loneliness was reduced.

Infection control audits and checks were carried out. The registered manager spoke positively about the commitment and dedication which staff had shown throughout the pandemic, which had helped to minimise the impact on people’s health and wellbeing.

Windermere Grange Care Home is a residential care home. The service accommodates up to 64 people over two floors divided into four wings. Two wings provide care and support to people living with a dementia. People living with learning disabilities are supported in the other two wings. At the time of inspection 56 people were using the service.

The service has been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

People’s experience of using this service and what we found

At our last inspection medicines were not always managed safely. Risks to some people's health were not fully assessed. People living in the learning disability service lacked choice and control over their lives and had limited inclusion in meaningful activities. Care and support plans were not always person-centred and did not reflect people's specific needs and future goals. Infection control measures were not always followed. Some staff needed specific training to support people with learning disabilities. The service's quality assurance processes were not robust.

At this inspection we found medicines were managed safely. However, some improvements were needed in the management of topical creams. Risks to people were recognised and actions were taken to reduce any risks identified. Staff knew what to do if they suspected anyone was at risk of abuse. They were confident the management team would act on any concerns raised. The providers recruitment procedures reduced the risk of unsuitable staff being employed. Infection control measures were followed by staff.

Care and support plans were comprehensive, person centred and regularly reviewed. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. Staff received the induction, training and support to carry out their roles well.

People and relatives told us staff were kind and caring. People’s independence was promoted. People were able to take part in a range of activities. Positive feedback was received about the management team. A system of audits and checks were in place to monitor the quality and safety of the service.

The learning disability service was situated off the main residential home with its own secure entrance. At the time of the inspection there were 16 people with learning disabilities living in the service. The size of this service is larger than current best practice guidance. However, this did not have a negative impact on people due to its design and how it was discreetly positioned away from the main residential care home.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 22 March 2019). There were breaches of regulation related to person centred care, safe care and treatment and good governance. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Windermere Grange accommodates 50 people over two floors and within four separate wings. The service had two specialised services which provided care to people living with dementia and care and support for people with learning disabilities.

The learning disability service was situated off the main residential home with its own secure entrance. At the time of the inspection there were 14 people living in the service. The size of this service is larger than current best practice guidance. However, this did not have a negative impact on people due to its design and how it was discreetly positioned away from the main residential care home.

What life is like for people using this service: Since our last inspection the provider had failed to maintain consistent high quality standards of practice within the service.

Medicines were not always managed safely; quality monitoring systems had not picked up on areas of improvements required.

Outcomes for people living in the learning disability service did not fully reflect the principles and values of Registering the Right Support; people lacked choice and control over their lives and had limited inclusion in meaningful activities.

Staff raised concerns regarding low staffing levels within the residential care service at certain times of the day.

Care and support plans were not always person-centred and did not reflect people’s specific needs and future goals.

Risks to people’s health were not always assessed to provide staff with the necessary guidance on how to keep people safe.

Staff did not always follow the providers infection prevention and control procedures; they did not use personal protective equipment (PPE).

Some people's dietary needs were accurately recorded. Referrals to speech and language therapy (SALT) were made when required.

Staff received training in line with the providers policy. Some staff needed specific training to support people with learning disabilities. We have made a recommendation for this training to be provided so staff can positively support people who have a learning disability.

The service’s quality assurance process was not robust as audits failed to identify the issues we found on our visit.

Staff stated they felt supported by the registered manager. Complaints procedures were in place to address any issues raised at the service.

The service worked with other organisations and agencies to promote people’s health and wellbeing. People had access to their GP or health professionals when needed.

Rating at last inspection: Good (last report published 22 February 2018).

Why we inspected: This was a planned inspection following the opening of a new learning disability service in December 2018.

Action we told provider to take: We identified three breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014 around person-centred care, safe care and treatment and good governance. Details of action we have asked the provider to take can be found at the end of this report.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

For more details, please read the full report which is on the CQC website at www.cqc.org.uk.

Windermere 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

Windermere Grange Care Home accommodates 72 people in a purpose built home across two separate floors. The ground floor accommodation was for people with residential care needs (Blossom) and people with a learning disability (Coniston). The first floor was a residential unit where some of the people were living with a dementia type illness (Poppy). On the day of our inspection there were 61 people using the service.

The registered manager had left the service in September 2017. In the interim the provider had appointed the deputy manager as acting manager with support from a senior management team. At the time of our inspection there was a new manager in post who was applying to become registered with CQC. A registered manager is a person who has registered with 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 2008 and associated Regulations about how the service is run.

Windermere Grange Care Home was last inspected by CQC on 18 and 21 October 2016 and was rated Requires Improvement overall and in two areas; safe and well-led. We informed the provider they were in breach of Regulation 18: staffing.

Whilst completing this visit we reviewed the action the provider had taken to address the above breach of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found that the provider had ensured improvements were made in this area and this had led the home to meeting the above regulation.

Accommodation is provided across two floors. Facilities included several lounges and dining rooms, communal bathrooms, shower rooms and toilets, hairdressing room, a large well maintained communal garden and a spacious reception area.

We saw that entry to the premises was controlled by key-pad entry and all visitors were required to sign in.

The layout of the building provided adequate space for people with walking aids or wheelchairs to mobilise safely around the home and was suitably designed for people with dementia type conditions.

The provider had procedures in place for managing the maintenance of the premises.

People who used the service and their relatives were complimentary about the standard of care at Windermere Grange Care Home. We saw staff supporting and helping to maintain people’s independence. People were encouraged to care for themselves where possible.

People were treated with respect and the staff understood how to provide care in a dignified manner and respected people’s right to privacy.

The staff knew the care and support needs of people well and took an interest in people and their relatives to provide individual personal care.

Staff had completed training in safeguarding of vulnerable adults and knew the different types of abuse and how to report concerns. Thorough investigations had been carried out in response to safeguarding incidents or allegations.

The provider had an effective recruitment and selection procedure in place and carried out relevant checks when they employed staff. There were sufficient numbers of staff on duty in order to meet the needs of people using the service.

Staff were supported to provide care to people who used the service through a range of mandatory and specialised training, supervision and appraisal.

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

People were protected against the risks associated with the unsafe use and management of medicines.

People had access to food and drink throughout the day and we saw staff supporting people to eat and drink at meal times when required. People’s weight and nutrition was closely monitored.

People had access to a range of activities in the home and within the local community.

All the care records we looked at showed people’s needs were assessed. Care plans and risk assessments were in place where required and daily records were up to date. Care plans were written in a person centred way and were reviewed regularly.

Staff used a range of assessment tools and kept clear records about how care was to be delivered. People who used the service had access to healthcare services and received ongoing healthcare support.

The provider had a complaints policy and procedure in place and complaints were fully investigated. Staff we spoke with told us they felt able to approach the registered manager and felt safe to report concerns.

The provider had a robust quality assurance system in place and gathered information about the quality of their service from a variety of sources.

The service had policies and procedures in place that took into account guidance and best practice from expert and professional bodies and provided staff with clear instructions.

At the last inspection on 29 July, 11 and 28 August 2015 we rated Windermere Grange Care Home as requires improvement. We found that the lack of effective oversight meant that for a number of months the home had ran below the staffing levels required from the provider’s own dependency tool. The process for analysing accidents and incidents needed to be improved in order to allow staff to identify trends and any preventative action that could be taken in the home. Alongside this, the audits failed to identify when care records were not accurately reflecting people’s needs; that Deprivation of Liberty Safeguard authorisations and the associated conditions were not reflected in individuals’ notes and staff were not contacting GPs to follow up changes in medication.

The registered provider sent us information to detail the actions that would be taken to make the necessary improvements.

Windermere Grange is a purpose built care home providing care for up to 72 people. The ground floor accommodates older people and since the last inspection a separate unit has been developed for people with a learning disability. The first floor accommodates older people living with dementia. All bedrooms are single occupancy with en-suite facilities and there are a number of lounge and dining areas.

The home has a manager in post who became the registered manager in September 2014. 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 who used the service and their relatives told us the staff were always very busy supporting people so had limited time with each individual. We visited from the early hours of the morning and spent time with people in each of the units. We found that the 68 people who used the service required varying levels of support. Staff worked hard to support people safely but staffing levels were not always sufficient to provide effective care. When we arrived to begin the inspection we saw staff were busy assisting people to get up and have their breakfast. Staff did not always have time to complete their support of one person before helping another. For example, we saw one person sitting in a bathroom with the door open as the member of staff helping them had been called away to assist someone else. We found that the staffing levels needed to be reviewed to ensure staff could also meet demands through the night and have time to complete all of their tasks.

At the last inspection when we reviewed the dependency tool, we found this to be extremely difficult to use and were unable to determine how staffing levels were calculated. However, the registered manager confirmed that the staffing levels had been below those set out by senior managers in the organisation. Since the last inspection the previous operational manager had reviewed the registered provider’s staffing calculation tool. A new tool had been developed but not implemented so staff remained reliant on the previous one. The new operational director told us that ensuring staffing levels consistently met people’s needs, was an area they were working on as a priority.

Staff had received Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards training and clearly understood the requirements of the Act, which meant they were working within the law to support people who may lack capacity to make their own decisions. However, staff were unclear about how to fill in the recently introduced Mental Capacity assessment forms. The registered manager had identified that staff needed additional support to ensure they had the skills and knowledge to consistently work with the Mental Capacity Code of Practice. They had organised training for staff around capacity assessments.

Following the last inspection a member of the public shared with us information from the Ombudsman and their investigation of the events leading up to the death of their relative in 2013. Following the review of the complaint the Ombudsman found that the home needed to make improvements to the way in which night time check records were completed as it could not be established the times of the checks. We looked specifically at the information staff now recorded around checks made during the night and found an accurate record was maintained.

At the last inspection we found that some improvements were needed in the way the staff managed medicines. We found that one person had not received appropriate pain relief as staff had not collected the person’s prescription in a timely manner. At this inspection we reviewed the systems for the management of medicines and found that people received their medicines safely and on time.

People’s needs were assessed and care was delivered in line with their individual care needs. The care plans contained comprehensive and detailed information about each person. However the complexity of the document and time constraints faced by staff led to not all of the support plans being updated in a timely manner. We discussed this with the registered manager and operational director who confirmed they had recognised the difficulties the current care records posed and so were in the process of introducing a new format. Following the inspection we were sent a copy of the new templates, which appeared easier to follow and less repetitive.

Staff had received a wide range of training, which covered mandatory courses such as fire safety as well as condition specific training such as dementia and diabetes. The operational director told us that not all of the staff had received refresher training but they had contracted a new training company to complete the annual training programme.

People we spoke with told us they felt safe in the home and the staff made sure they were kept safe. We saw there were systems and processes in place to protect people from the risk of harm.

People were supported to maintain good health and had access to healthcare professionals and services. People were supported and encouraged to have regular health checks and were accompanied by staff or relatives to hospital appointments.

People told us they were offered plenty to eat and assisted to select healthy food and drinks, which helped to ensure that their nutritional needs were met. We saw that individuals’ preferences were catered for and people were supported to manage their weight and nutritional needs.

The interactions between people and staff were jovial and supportive.

People who used the service and staff were extremely complimentary about the support the registered manager provided and told us that they were always accessible and available to discuss any issues at the home.

We saw that the provider had a system in place for dealing with people’s concerns and complaints. The registered manager ensured that concerns were thoroughly investigated. People we spoke with told us that they knew how to complain.

Effective recruitment and selection procedures were in place and we saw that appropriate checks had been undertaken before staff began to work in the home. The checks included obtaining references from previous employers to show staff employed were safe to work with vulnerable people.

Regular surveys, resident and relative meetings were held and we found that the information from these consultations were used to inform developments in the home such as the change in menus.

Checks of the building and maintenance systems were undertaken.

We found the provider was breaching one of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This related to the staffing. You can see what action we took at the back of the full version of this report.

One person and their relative told us, 'As soon as we walked into this home, we got a warm feeling.' Another relative we spoke with told us, 'The staff are very nice actually.' A visitor we spoke with told us, 'I like the place, I know the staff very well.' One person we spoke with told us, 'The staff are very good, they do the best they can.'

We saw that care records contained the information needed to provide appropriate care and support to people. People and their relatives confirmed they had been able to access care plans and were happy with the care provided.

People were given food and hydration in sufficient quantities. The manager told us about recent changes to the menus. People we spoke with were very complimentary about the food trolleys which came around during the morning and afternoon.

We saw Windermere Grange was clean and tidy. Staff we spoke with were very knowledgeable about the action which they took about infection prevention control.

People were provided with the equipment which they needed. We looked at records which showed that equipment was serviced regularly and repaired when needed.

Windermere Grange took appropriate action to ensure the quality of the service.

We spoke with three relatives of people who used the service. One relative said, 'The staff are lovely, I am involved in my mums care.' Another relative said, 'I am happy with the care and have no complaints.'

We found that people were treated with dignity and respect. We saw there was a friendly and relaxed atmosphere between people living and working at the home. We observed staff interacting well with people and supporting them which had a positive impact on their wellbeing.

We saw that people who used the service had a choice of food and drink and where required people were assisted to eat and drink. We found that people had nutrition care plans and 24 hour food and drink record charts which were up to date.

We found people were cared for by staff who were supported to deliver care safely and to an appropriate standard.

We found there was an effective complaints system in place at the home.