16 June 2023
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.
As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
The inspection was carried out by 1 inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service
Service and service type
Enderby Grange is a ‘care home.’ People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Enderby Grange is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.
At the time of our inspection there was a registered manager in post.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.
During the inspection
We spoke with 5 people who used the service and 8 family members about their experience of the care provided. We spoke with the registered manager, the deputy manager, 4 care assistants and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.
We reviewed a range of records. This included 3 people's care records. We looked at 2 staff files in relation to recruitment. A variety of records relating to the management of the service were also reviewed. This included quality monitoring tools, minutes of meetings and the staff training matrix
16 June 2023
About the service
Enderby Grange is a residential care home providing accommodation for people who require personal care to up to 40 older people, some of whom are living with dementia. The service is a purpose-built home, providing bedroom and communal rooms on both the ground and first floor. At the time of our inspection there were 33 people using the service.
People’s experience of using this service and what we found
Visiting professionals and many staff said communication could be improved to ensure all staff were up to date as to people’s health, wellbeing, and care needs.
A majority of family members told us the management team listened and acted upon any issues they raised. People spoke of their confidence to raise concerns, and of the positive relationships they had with the management team and care staff. Staff told us they worked effectively as a team and that the management team supported them.
People and most family members were complimentary about the care.
The provider had systems in place to monitor and improve the quality of the service provided. The provider sought the views of relatives, and working with other stakeholders, including social and health services.
Potential risks to people were assessed and kept under review. Measures were put in place to reduce potential risks and included learning from incidents, for example; increased monitoring and observations of people by staff who had been identified as being at high risk of falling.
People were supported by sufficient staff who had undergone a robust recruitment process and had undertaken training in topics to promote their safety. Medicine systems and practices were managed safely. People lived in an environment which was well maintained and clean, with safe infection and prevention measures.
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. People spoke of their independence being promoted.
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 20 May 2022).
Why we inspected
We received concerns in relation to the medicine management, infection control and the management of risk in relation to people’s care. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
The overall rating for the service has remained the same based on the findings of this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Enderby Grange on our website at www.cqc.org.uk.
We will continue to monitor information we receive about the service, which will help inform when we next inspect.