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

Inspection Summary

Overall summary & rating


Updated 23 November 2017

This inspection took place on 7 November 2017 and was unannounced.

Walsham Grange is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Walsham Grange accommodates up to 75 people, some of whom may be living with dementia, in one adapted building. At the time of our inspection there were 34 people living in the home.

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.

At our last comprehensive inspection on 14 and 15 March 2017 we found that the service was not meeting the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider was in breach of the regulations for safe care and treatment and good governance. During this inspection the service demonstrated to us that improvements have been made and is no longer in breach of the regulations.

The CQC is required to monitor the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and report on what we find. Whilst MCA assessments had been carried out, decisions made in people’s best interests were not always documented. We have made a recommendation about this.

Staff received training relevant to their role and this training covered a number of conditions that people may be living with. Staff compliance with training had improved but there were still some staff that had not completed all of the mandatory training set out by the provider.

Staff had regular supervision with a senior member of staff where they could talk about any personal or professional concerns in private. New staff completed an induction and would shadow an experienced member of staff before they worked independently.

People were supported to maintain a healthy nutritional intake and risks relating to people’s nutritional intake had been identified and mitigated. People’s weights were monitored and where needed, people’s food and fluid intake was monitored to ensure that they were maintaining a sufficient amount of food and fluid.

Timely referrals were made to other healthcare professionals such as the GP or district nurses where concerns were identified about a person’s health or wellbeing.

People’s individual risks were identified and detailed risk assessments gave staff guidance about how to manage known risks. Environmental risks were routinely assessed and remedial action was taken when hazards were identified. Servicing of lifting equipment and utilities regularly took place.

There were enough staff on duty to support people and people’s dependency was reviewed on a monthly basis to ensure that there were enough staff to meet people’s care needs.

People’s medicines were stored, managed and administered in a safe way. Staff who were responsible for administering people’s medicines had received training in this area. Topical medicines such as creams and ointments were applied as prescribed and there were also safe practices around the application of pain patches.

The home was clean and tidy. There were a team of domestic staff who worked in the service who maintained a good standard of cleanliness. Staff were observed to be wearing disposable gloves and aprons where needed.

Accidents and incidents were recorded and analysed for any trends or patterns. Steps were taken to reduce further occurrences.

People were supported by staff who were kind and caring. Staff interacted with people in a warm and friendly manner and knew how to offer reassurance to people when they became distressed. Staff showed interest in people and kn

Inspection areas



Updated 23 November 2017

The service was safe.

Individual risks to people were identified and steps had been taken to manage known risks.

Staff knew what constituted abuse and how to report any concerns.

There were enough staff to meet people’s needs and there were safe recruitment processes in place.

People’s medicines were stored and managed in a safe way and staff had received the correct training to administer people’s medicines.

The home was clean and tidy and there were infection control procedures in place.

Accidents and incidents were documented and monitored.



Updated 23 November 2017

The service was effective.

Decisions made in people’s best interests were not always documented.

Staff had received training relevant to their role but not all staff had completed the required training.

People’s mental capacity had been assessed where required and appropriate applications to deprive them of their liberty had been submitted to the relevant authorising body.

People were supported to maintain a healthy nutritional intake and where people were nutritionally at risk, appropriate advice was sought.

Prompt referrals were made to relevant healthcare professionals where there were concerns about a person’s physical health or wellbeing.



Updated 23 November 2017

The service was caring.

People were supported by staff who were kind and caring.

People were encouraged and supported to maintain their independence.

Staff were deployed to ensure that people’s needs were met in a caring way.

Staff treated people with respect and upheld people’s right to privacy.



Updated 23 November 2017

The service was responsive.

People’s care records were detailed and person centred and staff had a good understanding of people’s individual needs.

People and their relatives were involved in the planning of their care.

People could access a range of activities provided within the home but one to one activities for people being cared for in their rooms was not provided.

There was a complaints procedure in place and people felt able to raise any concerns with the registered manager.

Staff had a good understanding of how to care for people at the end of their life and further improvements were being made in this area.


Requires improvement

Updated 23 November 2017

The service was not consistently well led.

There were processes in place to monitor and assess the quality of service being delivered but these were not always effective in identifying shortfalls.

The registered manager was approachable and open to discussion.

Staff were motivated and morale within the staff team was good.

The registered manager worked with other services to assess the service and what improvements they could make.