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Archived: Capel Grange Private Residential Home Requires improvement

The provider of this service changed - see new profile

Inspection Summary

Overall summary & rating

Requires improvement

Updated 6 November 2015

The inspection was carried out on 14 September 2015 by two inspectors and an expert by experience. It was an unannounced inspection. The service provides personal care and accommodation for a maximum of 38 older people. There were 32 people living at the service at the time of our inspection. People had varied communication needs and abilities. Most of the people were able to talk with us about their experiences.

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 2008 and associated Regulations about how the service is run.

The registered manager was supported by a team of senior carers to ensure the daily management of the service.

People’s medicines had not always been managed in a safe way. Policies for the safe storage and administration of medicines had not been followed consistently.

Risk assessments had not been carried out in respect of all risks to the safety of individuals, for example there was no a risk assessment in place for a person who staff said was at risk of choking. Where people used pressure relieving mattresses there was not a plan in place to help them reposition frequently to further reduce the risk of damage to their skin.

Records about people’s needs and the care provided were not accurately or consistently maintained.

You can see what action we have asked the provider to take at the end of this report.

Accidents and incidents were recorded and monitored to identify how risks of re-occurrence could be reduced.

Staff were trained in how to protect people from abuse and harm. They knew how to recognise signs of abuse and how to raise an alert if they had any concerns.

There were sufficient staff on duty to meet people’s needs. Staff had time to spend supporting people in a meaningful way that respected individual needs. Staffing levels were calculated according to people’s needs and were flexible to respond to changes in need.

There were safe recruitment procedures in place. These included the checking of references and carrying out disclosure and barring service checks for prospective employees before they started work. All staff were subject to a probation period and disciplinary procedures if they did not meet the required standards of practice.

People lived in a clean and well maintained environment. Staff had a clear understanding of infection control practice that followed the Department of Health guidelines, which helped minimise risk from infection. The premises were appropriate for the needs of people living with dementia.

Assessments of people’s capacity were carried out in line with the Mental Capacity Act 2005.

People’s wellbeing was promoted by regular visits from healthcare professionals. People were usually supported to seek advice from relevant health professionals in relation to their specific health needs, but a professional assessment of a person’s swallowing difficulties had not been sought before providing the person with a soft diet. We have made a recommendation about this.

Staff had appropriate training and experience to support people and meet their individual needs. Staff were provided with the opportunity undertake a relevant health and social care qualification and were supported in their roles.

People were provided with sufficient food and drink to meet their needs. They were provided with a choice of meals.

The premises met the needs of the people that lived there. The registered manager had a good understanding of how to provide an appropriate environment for the needs of people living with dementia. They had provided signs to help people find their way to the bathroom and had used contrasting colours to ensure people with visual difficulties could identify facilities and areas of the service.

Staff were caring and kind in their approach towards people and they were sensitive to each individual’s needs, giving reassurance where needed and encouraging people. Staff respected people’s privacy and confidentiality. People were happy with how their care and treatment was delivered.

Staff knew each person well and understood how to meet their support needs. Each person’s needs and personal preferences had been assessed before they moved into the service and were continually reviewed. Staff understood people’s needs and delivered personalised care.

People were involved in their day to day care. People’s care plans were reviewed with their participation or their representatives’ involvement. The staff promoted people’s independence and encouraged people to do as much as possible for themselves.

People’s bedrooms were personalised to reflect their individual tastes and personalities. There was a programme of social activities available to people that was based on their needs and interests.

The service took account of people’s complaints, comments and suggestions. People’s views were sought and acted upon. People’s relatives were asked about their views when they visited the home and when people’s care plans were reviewed. The service sent annual questionnaires to people’s relatives or representatives and analysed and sought to act upon the results of the surveys.

The service notified the Care Quality Commission of any significant events that affected people or the service and promoted a good relationship with stakeholders.

The registered manager kept up to date with any changes in legislation that may affect the service, and participated in monthly forums with other managers from other services where good practice was discussed. The registered manager and deputy manager carried out audits to identify how the service could improve. They acted on the results of these audits and made necessary changes to improve the quality of the service and care.

Inspection areas


Requires improvement

Updated 6 November 2015

The service was not consistently safe.

People’s medicines were not always managed safely.

Not all risks to individuals had been assessed and appropriately managed.

Staff were trained to protect people from abuse and harm and knew how to refer to the local authority if they had any concerns.

There were sufficient staff on duty to safely meet people’s needs.

Safe recruitment procedures were followed in practice.

The environment was secure, well maintained and cleaned to a good standard.



Updated 6 November 2015

The service was not consistently effective.

The registered manager had not always ensured the requirements of the Mental Capacity Act 2005 were met in respect of people making decisions about receiving treatment.

Appropriate referrals to health professionals had not always been made for people’s eating and drinking needs.

Staff in care roles were trained and had a good knowledge of each person and of how to meet their specific support needs.

The registered manager had ensured that relevant applications to the statutory authority in relation to Deprivation of Liberty Safeguards office had been submitted.

The premises were suitable for the needs of the people using the service.



Updated 6 November 2015

The service was caring.

Staff communicated effectively with people and treated them with kindness and compassion.

Staff promoted people’s independence and encouraged them to do as much for themselves as they were able to.

People’s privacy and dignity was respected by staff.



Updated 6 November 2015

The service was responsive.

People’s care was personalised to reflect their wishes and what was important to them. Care plans and risk assessments were reviewed and updated when needs changed. The delivery of care was in line with people’s care plans.

The service sought feedback from people and their representatives about the overall quality of the service. Complaints were addressed promptly and appropriately.


Requires improvement

Updated 6 November 2015

The service was not consistently well led.

Records were not fully completed or consistently maintained in respect of some aspects of people’s needs and the care provided.

There was an open and positive culture which focussed on people. The manager operated an ‘open door ‘policy, welcoming people and staff’s suggestions for improvement.

There was an effective system of quality assurance in place. The registered manager carried out audits and analysed them to identify where improvements could be made.