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Capwell Grange Care Home Inadequate

The provider of this service changed - see old profile

Inspection Summary

Overall summary & rating


Updated 24 October 2020

About the service

Capwell Grange is a nursing and residential care home providing personal and nursing care to up to 146 people.

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

We had concerns about how the service promoted people’s safety. We identified significant shortfalls with how the management team and provider were responding to COVID19. Safe processes were not always being followed to try and prevent the spread of the virus. The service was not always adhering to government guidelines in relation to COVID19. After we had visited the service and identified these concerns there was an outbreak of COVID19 at the service.

We also found people’s safety was not being considered in terms of injuries or when something went wrong. Investigations did not take place in a timely way and as a matter of course when potential harm had occurred. We needed to prompt the management team to complete investigations when something had potentially gone wrong. When we reviewed these investigation reports we found these were not always conducted in an open way.

There had been some safeguarding events at the service which had prompted us to inspect. Staff did not have a clear understanding about what abuse could look like. An internal investigation found some staff were aware of these concerns, but they had not told anyone in the management team or outside of the organisation such as the local authority or police about this abuse. There was a poor staff culture and we found evidence of institutional practice. People were not always valued and treated with dignity and respect, especially people living with dementia or with behavioural needs. We raised safeguarding referrals to the local authority about our concerns.

Concerns had been raised by the local authority about how people’s general nursing care needs were being managed at the home. Some improvements had been made as a result of the local authority identifying issues with wound care. However, we still found shortfalls in this area of care. Nurses did not receive competency checks of their practice, despite these identified concerns. Other areas of clinical practice at the service were not checked by the provider to see if staff were actually effective in their work. We also identified shortfalls in staff’s understanding and knowledge about abuse and harm.

Staff did not feel they could talk with the management team and raise issues. They did not feel supported or valued by the provider. Staff did not question practice or promote people’s rights, to ensure they were safe and happy in their daily life. This increased the risk of abuse or harm occurring. There were a number of safeguarding investigations taking place at the service.

The provider had systems to assess the quality of the service, where issues had been duly identified and reported on. However, the provider did not have effective systems to respond to these. Meaningful action plans were not created to make improvements, nor further checks completed to test if these plans had been successful.

As a result of our findings the provider placed a voluntary embargo stopping admissions for a temporary period. We were also given verbal assurances that the provider will be making positive changes to the service to improve people’s experiences, in a timely way.

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The rating at the last inspection was requires improvement, the report was published on 25 May 2019. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Capwell Grange on our website at

Why we inspected

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

The overall rating for the service has changed from

Inspection areas



Updated 24 October 2020

The service was not safe.

Details are in our safe findings below.


Requires improvement

Updated 24 October 2020



Updated 24 October 2020



Updated 24 October 2020



Updated 24 October 2020

The service was not well-led.

Details are in our well-Led findings below.