Archived: Thelwall Grange Care Home

Updated 3 November 2021

The inspection

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 Care Act 2014.

Inspection team

The inspection visit was carried out by two inspectors and an inspection manager.

Service and service type

Thelwall Grange 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.

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

The inspection was unannounced.

Inspection activity started on 25 August 2021 and ended on 02 September 2021. We visited the service on 25 August 2021.

What we did before the inspection

We reviewed the information we received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used all of this information to plan our inspection.

During the inspection

We spoke with five people who used the service about their experiences of the care provided. We also spoke with the registered manager and deputy manager. We reviewed a range of records. This included people’s care records and a sample of medication records. We looked at safeguarding and incident and accident records and the recruitment records for one staff member employed since the last inspection.

After the inspection visit

Due to the impact of the COVID-19 pandemic we limited the time we spent on site. We reviewed records and documentation sent to us following the inspection visit and spoke over the telephone with seven staff members including care workers and ancillary staff.

Updated 3 November 2021

About the service

Thelwall Grange is a care home providing accommodation, and personal care for up to 47 younger and older adults; some of whom lived with dementia and physical disabilities. At the time of the inspection 47 people were using the service.

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

Systems and processes to safeguard people from the risk of abuse were not followed. Staff and managers had failed to raise safeguarding concerns when people had been placed at risk from harm and abuse.

Lessons were not learnt, and improvements made when things went wrong within the service. Appropriate action was not taken in response to incidents which occurred at the service and there was a failure to follow disciplinary procedures and address staff performance.

There was a failure to promote a positive culture within the service. The provider resisted information sharing and engagement with stakeholder organisations who were working to keep people safe. There was a culture of staff not reporting concerns which placed people at risk of harm and abuse. Staff told us they didn’t feel confident in raising concerns directly with the provider or managers.

We were assured that Infection prevention and control measures were followed to minimise the risk of the spread of infection, including those related to COVID-19.

Medicines were managed safely. Medication administration records (MARs) were completed with up to date information about people’s prescribed medicines and when they were given.

The recruitment of staff was safe. A range of pre- employment checks were carried out on applicants to assess their fitness and suitability for the role.

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 good (published 12 June 2021).

You can read the report from our last inspection, by selecting the ‘all reports’ link for Thelwall Grange Care Home on our website at www.cqc.org.uk.

Why we inspected

We received concerns in relation to people’s safety and the leadership of the service. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

Our report is only based on the findings in those areas at this inspection. The ratings from the previous inspection for the effective, caring and responsive key questions were not looked at during this visit. We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used to calculate the overall rating at this inspection.

We looked at infection prevention and control measures under the ‘safe’ key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service has changed from good to inadequate. This is based on the findings at this inspection.

We have identified breaches in relation to safeguarding people from the risk of abuse and harm and the governance of the service. Please see the safe and well-led sections of this full report.

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

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.