Cheadle Grange Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

This is the first assessment for this newly registered. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff understood the process for reporting and recording incidents. Investigations were carried out to identify learning. We saw examples where duty of candour was followed.

The provider had systems and processes in place for oversight of incidents. Quality assurance checks were completed monthly by the management team. They reviewed potential themes and trends. This helped identify learning across the service and supported ongoing improvement.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Pre-admission assessments were completed to ensure people’s needs were met safely and effectively. Staff worked closely with other healthcare professionals. Appropriate referrals were made to other services, such as GP and speech and language therapist (SALT). Staff escalated concerns so people’s needs were assessed for improvement or deterioration. Care plans were updated when people’s needs changed.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People told us they felt safe living at Cheadle Grange. Staff received safeguarding training. They knew how to protect people from abuse and who to report concerns to. The registered manager worked with the local authority to raise and investigate safeguarding concerns.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that people’s capacity and ability to consent was considered. The provider had systems in place relating to the Mental Capacity Act (MCA). Capacity assessments had been completed. People were supported to make decisions, and there was information to show people’s preferences had been considered.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff knew how to keep people safe. Risks were identified and mitigated. People’s care plans included guidance for staff on how to protect people from identified risks.

People had individual risk assessments relating to the care and support they received. These included risks relating to eating, drinking, moving and handling, skin integrity and falls.

We observed staff supporting people to eat and using equipment safely.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The building was designed with communal spaces. Bedrooms, bathrooms and communal areas were spacious, accessible and suitable for people using mobility equipment. We observed the corridors were clear and escape routes free from obstructions, supporting people to move around safely and independently. We were told by a relative, “It’s a clean, nice, environment and it is tastefully decorated. To be honest I would be happy there if my time came.”

Routine health and safety checks were completed. Systems were in place to maintain the premises and equipment. Fire arrangements were in place with regular reviews of personal emergency evacuation plans (PEEPs). The kitchen and food preparation areas were clean, well maintained and managed safely.

The provider had considered some aspects of the environment to support people living with dementia, including providing seating within the corridor. There were opportunities to further develop this, including with appropriate signage and access to outdoor space.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

Feedback from people using the service, relatives and staff was more staff were needed on each shift.

The provider used a tool to assess staffing levels. We saw this was not a true reflection of the care hours required, and feedback was there was not always enough staff. Some people raised concerns they could not have care when they wished. The provider had plans in place to address this.

The provider had a training matrix in place which evidenced staff had completed statutory and mandatory training. However, staff had not completed end of life care training.

The provider’s recruitment, disciplinary and capability processes were fair, transparent and reviewed to ensure fair recruitment. Disclosure and Barring Service (DBS) checks were carried out to ensure staff were of good character to support vulnerable people.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The home was visibly clean and tidy and domestic staff were visible around the home performing their duties.

Staff had completed infection prevention and control (IPC) training and had the equipment needed to carry out their role. Audits were carried out and local infection prevention control procedures were followed. Infections risks were discussed in meetings and spot checks completed.

The home had a food hygiene inspection and was rated 5 star by the local authority’s environmental health team. This meant food hygiene standards were very good and fully complied with the law.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People’s medicines were managed safely by trained and competent staff. Medicines were stored appropriately. High-risk medicines were clearly identified to support staff to administer them safely to people. Plans for ‘as needed’ medicines, such as paracetamol for pain were detailed and person-centred.

Leaders completed regular medicine reviews and carried out medication audits to identify any concerns and areas for improvement.