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Archived: Latimer Grange Limited Inadequate

We are carrying out a review of quality at Latimer Grange Limited. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating


Updated 13 January 2018

The inspection took place over four visits on 3, 21 and 29 November 2017 and 6 December 2017. Each inspection visit was unannounced. We inspected the service due to concerns received about the provider, registered manager and two members of staff.

The last inspection of the service was on 3 July 2017, we found that the provider was in breach of Regulation 14 (1) (4) (a) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 because a person who was at risk of malnutrition had not had nutrition and hydration assessments carried out to ensure their nutritional needs were met.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to make the improvements required. We received an action plan from the provider on 14 September 2017 stating how they would make the necessary improvements. We found at this inspection that whilst action had been taken to make improvements these had not been sustained and as a consequence people’s nutritional and hydration needs were not being consistently met.

Latimer Grange is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

Latimer Grange is registered to accommodate 27 people in one adapted building. There are 23 bedrooms, 16 of which have ensuite facilities. There is a communal dining room, a communal lounge with three distinct areas and an enclosed landscaped garden with a covered seated smoking area.

The service has had a registered manager since 30 May 2017. 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 2008 and associated Regulations about how the service is run.’ The registered manager was absent from the service from 18 October 2017 and the absence was expected to continue to 15 January 2018 and possibly for longer. The provider had not notified CQC in writing of the registered manager’s absence.

People we spoke with were unanimous saying they were satisfied with the care and support they received. People’s relatives were also satisfied. However, we found serious concerns about the safety of the service.

When people were discovered to have injuries such as bruising, there was no attempt to identify the cause of the injuries. Risk assessments were not carried out to identify how people could be protected from avoidable injuries.

People were not adequately protected from the risk of falls. Risk assessments were not reviewed after people experienced falls. This demonstrated that the provider did not have effective systems for identifying learning after incidents occurred and making improvements.

People’s nutritional health was not adequately monitored. A person’s records showed they had suffered a significant weight loss in the space of two months. However, no action had been taken to review their nutritional risk assessment. This demonstrated the person had not had safe care and support.

We found the management of medicines to be inadequate. Two people had repeatedly refused to take their medicines. There was no strategy in place to understand why or what steps could be taken to protect people from the risks associated with not having medicines they required for their well-being. There were concerns when a staff member handled a person’s medicines without wearing gloves. Medicines for disposal were not stored securely or returned to the dispensing pharmacist in a timely manner.

An information folder that was intended for fire and rescue emergency services was inaccurate and out of date with regards to which rooms people occupied and who lived at Latimer Grange. This c

Inspection areas



Updated 13 January 2018

The service was not safe.

People had unexplained injuries that were not investigated. Risk assessments were not reviewed after incidents of injuries which exposed people to risk of further injuries.

Medicines management arrangements did not ensure that people were supported to have medicines they needed. A large amount of unused medicines were found that should have been returned to the supplying pharmacist.

A potential structural defect to part of the building had not been risk assessed. Fire safety information was not up to date.


Requires improvement

Updated 13 January 2018

The service was not consistently effective.

Assessments of people�s mental capacity were general assessments. The assessments did not focus on people�s capacity to understand or decide about specific aspects of their care and support.

People�s nutritional needs were not monitored and their food and fluid charts were not completed. People with diabetes were not supported to access sugar free alternative foods. The service did have a hypoglycaemia kit.

Staff were supported through training, but no actions were taken to ensure that staff kept up to date with their training.

Staff worked with health services to arrange healthcare visits to Latimer Grange and supported people to access health services when they needed them.


Requires improvement

Updated 13 January 2018

The service was not consistently caring.

The service had not ensured that people with sensory impairment were supported with their communication and information needs.

People told us that staff were kind to them and we observed several examples of that. Staff provided people with information about their care and support and external events that were having an effect on the running of the service.


Requires improvement

Updated 13 January 2018

The service was not consistently responsive.

People did not consistently experience personalised care and support that met their needs.

The service had not implemented the Accessible Information Standard to ensure that people with sensory impairments were supported to access or understand information relevant to their care and support.

People�s wishes about their end-of-life care were not recorded in their care plans.

People told us they knew how to raise concerns or make a complaint if the need arose.



Updated 13 January 2018

The service was not well led.

There were widespread shortfalls in the quality of care and support which left people exposed to the risk of harm and unsafe care. Lessons were not learnt after people had injuries or poor care.

The leadership and management of the service was inadequate. There was no credible plan of the provider�s aims and objectives for people and staff. There was no monitoring to check that people�s needs were being met or to identify and implement improvements to people�s experience of the service.

The interim management arrangements during the registered manager�s absence were not supportive of the interim manager.