Archived: Capwell Grange Care Home

Updated 19 January 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection took place on 9 and 11 November 2016, and it was unannounced. It was carried out by an inspector, a specialist advisor who is a nurse with experience of supporting people living with dementia, and two experts by experience on 9 November 2016. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service. Only the inspector visited the service on 11 November 2016 and we completed the inspection on 23 November 2016 when we had received feedback from all members of the inspection team.

Before the inspection, we reviewed information we held about the service, including the previous inspection report and notifications they had sent us. A notification is information about important events which the provider is required to send to us. We also reviewed information of concern we had received in the last 12 months either from the local authority, members of the public or staff.

During the inspection, we spoke with 16 people who used the service, nine relatives, 16 staff including care staff and some nurses, the clinical services manager and the registered manager.

We looked at the care records for 12 people who used the service. We reviewed the provider’s staff recruitment, supervision and training processes. We checked how medicines and complaints were being managed. We looked at information on how the quality of the service was assessed and monitored, and we observed how care was being provided in communal areas of the home.

Updated 19 January 2017

This unannounced inspection took place when we visited the service on 9 and 11 November 2016. It was completed on 23 November 2016 when we had received feedback from all members of the inspection team.

The service provides care and nursing support to people with a variety of needs including those living with dementia, physical disabilities, mental health needs and chronic health conditions. On the day of our inspection, there were 142 people being supported by the service.

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.

Potential risks to people’s health, safety and welfare had been reduced because there were risk assessments in place that gave guidance to staff on how to support people safely. There were systems in place to safeguard people from avoidable harm and staff had been trained in safeguarding procedures. The provider had effective recruitment processes in place and there was sufficient staff to support people safely. People’s medicines were managed safely.

Staff had regular supervision and they had been trained to meet people’s individual needs. They understood their roles and responsibilities to seek people’s consent prior to care and support being provided. The requirements of the Mental Capacity Act 2005 (MCA) and the related Deprivation of Liberty Safeguards (DoLS) were being met.

People were supported by staff who were kind, caring, friendly and respectful. They were supported to make choices about how they lived their lives and how they wanted to be supported. People had enough to eat and drink to maintain their health and wellbeing. They were supported to access other health services when required.

People’s needs had been assessed and they had care plans that took account of their individual needs, preferences, and choices. Where possible, people and their relatives had been involved in reviewing people’s care plans. People had been provided with a variety of activities facilitated by activities coordinators on each unit.

The provider had a formal process for handling complaints and concerns. They encouraged feedback from people who used the service, their relatives, external professionals and staff, and they acted on the comments received to continually improve the quality of the service.

The provider’s quality monitoring processes had been used effectively to drive continuous improvements. The manager provided stable leadership and effective support to staff, and promoted a caring and inclusive culture within the service. Staff were motivated to do their best to provide good care to people who used the service and to work in collaboration with people’s relatives.