Walsham Grange

Walsham Grange is a residential care home providing accommodation and personal care to up to 75 people. The service provides support to older people, some of whom are living with dementia. At the time of our inspection there were 50 people using the service.

Walsham Grange offers accommodation which is over two levels. There are various shared living areas in the home which include a quiet lounge, a conservatory and dining room. There are shared bathing facilities on each floor. Some bedrooms benefit from ensuite facilities.

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

Following the last inspection, the provider had reviewed the quality assurance processes in place. These required further time to become embedded and to support continual drive of improvement of the quality and standard of care in the home.

We received mixed feedback from relatives regarding the staffing levels in the home. A recruitment drive was ongoing and several new staff had joined the staff team. A process was in place to ensure staff were recruited safely.

Staff had completed infection control training and were knowledgeable of measure to take to apply this in their work. This included maintaining a clean environment, wearing of appropriate personal protective equipment (PPE) and practicing good hand hygiene.

People appeared to be relaxed and comfortable with staff. Staff were observed treating people with dignity, respect and kindness.

People received their medicine from trained and competent staff. The regional manager conducted checks of staff skill and knowledge to ensure they were safe in their practice.

An induction process was in place which prepared staff for their role. Staff told us they received a blend of face-to-face training as well as e-learning. In addition, the regional manager and senior staff team conducted checks of staff skills and practice. One staff member told us they had recently completed an in-house virtual dementia training session which had enhanced their knowledge and understanding of providing care for those living with dementia.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff felt supported by the management of the service and were happy in their role. One staff member told us, “This is the best caring environment I have worked in. The staff work well together and help each other. We get time to speak with people here and build a bond with them.”

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 requires improvement (published 28 June 2022) and there was a breach in regulation relating to governance. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We received concerns in relation to the management of falls and the governance of the service. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has remained requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the Safe and Well-led sections of this full report.

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

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Walsham Grange is a residential care home providing accommodation personal and nursing care up to 75 people. At the time of our inspection there were 55 people using the service. The home is in a converted period building set over two floors with lift access.

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

There had been improvements at the service since our last inspection, however further improvements were still required.

Governance systems required further development to ensure these were effective in assessing, monitoring and implementing improvements within the service.

Whilst improvements had been made in relation to the management of medicines, this still required further improvement. The review of accidents and incidents would also benefit from further development.

People felt they were cared for, and their care was planned and delivered in a person-centred way by staff who had a good understanding of people’s individual needs. People and their relatives were involved in the assessment, planning and review of care.

Staff understood their responsibilities in relation to keeping people safe and the reporting of safeguarding incidents.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People were supported to maintain a healthy nutritional intake and were able to access healthcare professionals when needed.

Surveys had been implemented to gather feedback from people who used the service, relatives and staff. Relatives reported that communication from the staff team was good.

Whilst further improvements were still required, feedback from relatives and staff acknowledged the progress made since the last inspection.

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 inadequate (report published 28 October 2019) and there were breaches of regulations. We met with the provider to discuss the improvements required and were given assurances about the actions that would be taken to make the improvements. At this inspection we found improvements had been made, although the provider remained in breach of one regulation.

This service has been in special measures since 28 October 2019. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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.

We have found evidence that the provider needs to make improvements. Please see the Safe, Effective, Caring, Responsive, 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.

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

Enforcement recommendations

We have identified a breach in relation to the provider’s governance systems at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request and action plan from the provider and will work alongside them and the Local Authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice.

Staff had continued to provide and adapt a diverse range of activities, during the COVID-19 pandemic, which were tailored to the needs to individual people who lived in the service to improve their wellbeing and engagement.

Relatives visiting had been flexible and creative to ensure they could take place. For example, a person who lived in the service could not normally leave their bed was able to go outside using a specialised chair, which was sourced specifically, so they could see their relative.

Staff organised for a person who lived at the service to attend the funeral of their close relative for their wellbeing and help with grief.

A journal had been created for each person which held details of their family, likes, wishes, goals and what activities they took part in. There were photos of the activities. This journal was a record of memories that could be shared.

Further information is in the detailed findings below.

Walsham Grange is a residential care home providing personal care to 53 people aged 65 and over. The service can support up to 75 people. The home is an adapted building set across two floors.

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

Individual risks relating to people’s health and wellbeing had not always been identified or planned for. Where risks had been identified, appropriate action was not always taken to minimise the risk of harm. Staff did not have a good understating of what constitutes abuse and how to report concerns. Learning did not take place after incidents and people’s care records were not always reviewed after an accident. Environmental risks were not always identified or well-managed.

Medicines were not managed in a safe way. People were not given their medicines as prescribed and there was insufficient written information about people’s medicines. There were poor practices relating to caring for people living with diabetes.

There were insufficient numbers of staff to support people safely and recruitment records were not always complete.

Staff did not always observe good practices around infection prevention and control and there was a malodour in some parts of the home.

Assessments of people’s care needs were not detailed and failed to identify the level of care people required.

New staff did not receive thorough inductions and staff had not completed all of their training set by the provider. The training staff had received was not sufficient for them to carry out their role effectively. Staff received regular supervision, but some appraisals were overdue.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. Mental capacity assessments were not always carried out and consent was not always sought from people’s authorised representatives.

There was poor assessment of people’s nutritional needs. Where people had been identified as being at risk of not maintaining a good nutritional intake, people did not receive the appropriate support. Staff did not always work collaboratively with other healthcare professionals to ensure people received timely care. We did however see some good practice in this area too.

Staff did not always treat people in a respectful way and uphold people’s dignity. Staff did not spend time to speak with people of engage people in activities. People’s communication and diverse needs had not been assessed.

People care was not planned in a person-centred way and care records were not up to date. There was no record of people’s life histories. People’s end of life wishes were not recorded.

There was a lack of systems in place to monitor and assess the quality and safety of service being delivered. Audits that were carried out were ineffective at identifying shortfalls and where shortfalls had been identified, timely action was not taken.

The form used to gain people’s views about the service was not sufficient as it did not give people the opportunity to provide feedback across all areas of the service. The registered manager had implemented feedback forms for relatives and was awaiting the responses.

Notifiable incidents were not always reported to CQC as required by law.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 23 November 2017).

Why we inspected

The inspection was prompted in part due to concerns received about medicines, safeguarding concerns and people’s care records. A decision was made for us to inspect and examine those risks.

We have found evidence that the provider needs to make improvements. Please see the full report.

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

Enforcement

We have identified breaches in relation to safe care and treatment, staffing, need for consent, meeting nutritional and hydration needs, dignity and respect, person-centred care and good governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will continue to monitor information we receive about the service until we 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.

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 knew how to communicate with people based on their individual needs. People were treated with respect and their privacy was maintained.

People were supported to be as independent as possible. People had adapted crockery and cutlery which enabled them to eat independently. Some people had mobility aids which meant that they could mobilise independently.

People and their relatives could attend meetings with the registered manager. They could put forward any suggestions about how the service is run and be informed of any changes within the service.

Staff tried to ensure that people and their relatives were involved in the care planning process. People’s care plans were detailed and person centred. People’s preferences and preferred ways of communicating were clearly documented.

There were a number of activities provided by dedicated activities staff. These ranged from arts and crafts to games such as table tennis. There was little in terms of activities for people who were being cared for in their rooms.

A complaints procedure was in place and the home had not received any complaints recently. People we spoke with told us that they would feel comfortable with raising a complaint if needed.

People and staff we spoke with told us that the serviced had improved and that staff morale was better. There were a number of quality monitoring processes that had been introduced and these had proved to be effective in improving the completion of paperwork relating to people’s care, in particular daily records.

Staff were involved in making decisions about how the service was run and this was done through regular staff meetings.

The registered manager and provider worked with other agencies to improve the quality of the service being delivered.

Walsham Grange provides accommodation and care for up to 75 people, many of whom would be living with dementia. At the time of our inspection 34 people were 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.

The service has been in Special Measures. Service that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

At our last comprehensive inspection on 5 and 6 April 2016 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, staffing and good governance. This was the second time that the provider was not meeting the regulation for good governance and as a result we issued a warning notice. This informed the provider why they were not meeting this requirement. They were required to be compliant by 17 June 2016.

We conducted a focussed inspection on 9 August 2016 to see whether the provider had met the requirements of the warning notice. We found that the necessary action to meet this requirement had not been taken and we placed the service in special measures. We imposed conditions on the provider’s registration. The provider was required to send us information every month about how they monitored and assessed the service being delivered to people.

At this inspection on 14 and 15 March 2017 we found that improvements had been made and the service was no longer in special measures. However, we still had concerns relating to the regulations for safe care and treatment and well led and the provider remains in breach of these regulations. Full information about CQC’s regulatory response to any concerns found during inspection is added to reports after any representations and appeals have been concluded.

There was a system in place to monitor the level of care people required and this was adjusted according to people’s changing care and support needs. This also determined how many staff were required to meet people’s needs effectively.

Steps to manage and mitigate risks to people’s health were not always taken. People who were nutritionally at risk did not always receive care appropriate to their needs and food and fluid charts were not always completed. Some people were at risk of developing pressure ulcers and required repositioning to minimise the risk of one developing. People were not always repositioned according to the guidance in their care plans. Records relating to the administration of creams were not always complete and we could not be assured that people were receiving these as prescribed.

During the inspection we found that there was exposed pipework which posed a risk to people if they fell on it. We also found that there was no risk assessment in place for the staff who lived on site. When we raised these concerns both the provider and manager took immediate remedial action.

The service had made a number of improvements since our last inspection. People living in Walsham Grange, their relatives and the staff all spoke of the service improving. During our inspection on 5 and 6 April 2016 we found that there were not enough suitably trained staff to care for people. As a result, the provider was in breach of the regulations for staffing. We found during this inspection that staff were more up to date with their training. We also received positive feedback regarding the numbers of staff and their ability to respond to people in a timely manner. The provider had made improvements in this area and they were no longer in breach of this regulation.

We saw that the way people’s care records were written had improved but sometimes they did not always identify risks to people’s health and wellbeing.

The CQC is required to monitor the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and report on what we find. We found that not everyone had an MCA assessment and decisions made for people in their best interests were not always documented. However, people reported that staff asked them for their consent before they did anything for them.

People were supported to access relevant healthcare professionals where there were concerns relating to their physical or emotional wellbeing.

Staff knew what constituted abuse and how to report any concerns and they had received training in safeguarding.

Appropriate recruitment practices were in place and relevant checks had been carried out on staff prior to them working in the home. This contributed to keeping people safe.

Peoples medicines were stored and administered in a safe way and regular audits were carried out to ensure the safe management of people’s medicines. Staff received regular training and supervision in this area.

The care that people received was variable and sometimes staff did not always treat people in a caring way. There were times during our inspection where people’s dignity was not always maintained. On the whole, people reported that staff were caring and treated them with respect.

Regular meetings took place for people and their relatives to attend so they could give their feedback on the service. In addition to this, a questionnaire had been given to people and their relatives which provider a further opportunity to give their opinions on the service.

We carried out an unannounced comprehensive inspection of this service on 5 and 6 April 2016. Three breaches of legal requirements were found and a warning notice was issued in relation to one of them which involved the governance of the service. We gave the provider until 17 June 2016 to meet the legal requirements of this regulation.

We undertook this focused inspection to check that the service had undertaken changes to meet the legal requirements of this regulation. This report only covers the findings in relation to the warning notice. You can read the report from our last comprehensive inspection in April 2016, by selecting the 'all reports' link for Walsham Grange on our website at www.cqc.org.uk.

At this inspection carried out on 9 August 2016 we found that there were still considerable concerns in relation to the governance of the home. We have not changed the overall rating for this service as a result of this inspection as it was only undertaken to follow up our enforcement action. The service remains requires improvement and the domain for well-led remains inadequate.

Walsham Grange provides residential and nursing care for up to 75 people, some of whom may be living with dementia. Accommodation is over two floors with a number of communal areas. Since our last inspection in April 2016, the service had closed its Grant Hadley unit which catered for people living with dementia. Although there were still people living with dementia residing in Walsham Grange, they had moved into the main house following appropriate consultation. At the time of this inspection, 44 people were living at Walsham Grange on a permanent basis, some of whom required nursing care.

At the time of this inspection, the home had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 previous inspection in April 2016, although the manager was in post, their application to become registered with the CQC was being processed.

At this inspection carried out on 9 August 2016 the registered manager was not available and the deputy manager was managing the home in their absence. The registered manager was due to be available on 15 August 2016 and we gave them the opportunity to submit any further information in relation to the warning notice up until 5pm on that day. Additional information was submitted within the timeframe given.

At the inspection in April 2016, concerns were identified that demonstrated that the provider did not have effective systems in place to monitor the quality and safety of the service delivered. This had resulted in some people receiving a poor service.

At this inspection we saw that although some improvements had been made, the service was still in breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 which relates to governance.

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Although additional processes had been introduced to monitor the quality and safety of the service the home delivered, these were not wholly effective. The service had failed to appropriately manage the concerns highlighted in this report. These included a lack of suitably trained and supported staff to meet people’s needs in a person-centred manner and failure to mitigate the future risk of accidents and incidents reoccurring. Issues in relation to medicines administration and management had not been identified by the service. There was also a lack of clear plans to action any concerns identified where the service fell short of the required standard.

Some processes that the service had introduced had resulted in some improvements being made. This included mitigating some risk of medicine administration errors and the identification and management of the risks associated with the building, environment, working practices and adverse events.

Walsham Grange provides residential and nursing care for up to 75 people, some of whom may be living with dementia. Accommodation is over two floors and there is a separate wing called the Grant Hadley unit to cater for those people living with dementia. At the time of our inspection, 54 people were living at Walsham Grange on a permanent basis.

There was a manager in post who had been appointed in February 2016. At the time of our inspection, the manager had submitted an application to the CQC to become a registered manager; their application was being processed. 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.

We last inspected this service on 28 and 30 April 2015 where 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 person-centred care, need for consent and good governance. The service was also in breach of the Care Quality Commission (Registration) Regulations 2009. This was because they had failed their legal obligations to report events to the CQC that affect people’s safety.

Following the inspection in April 2015, the service sent us a plan to tell us about the actions they were going to take to meet the above regulations.

At our inspection in April 2016, we found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

The service had appointed a new manager who had only been in post since February 2016. Although the manager had an open approach with us and told us the areas of the service that required improvement, the provider’s quality monitoring audits had not identified the issues highlighted in this report.

Medication management was not consistently safe. People did not always receive their medicines as the prescriber intended. The service had failed to maintain accurate and full records in relation to medicines administration and management.

The people who used the service, staff and visitors to the home were not protected from the risk of harm as the service was unable to produce risk assessments for the environment. Accidents and incidents were recorded and the manager had an overview of these. However, no formal analysis was completed in order to identify contributing factors or trends. This potentially put people at risk of harm. Individual risks to people had been identified, assessed and reviewed on a regular basis.

Staff knew how to identify and report potential abuse. The service had appropriately liaised with other agencies to manage identified concerns. However, the service did not always have the knowledge to take appropriate action to investigate those concerns and required guidance.

People’s social and leisure needs were not consistently met. Although staff interacted with the people they supported on a regular basis, little activities took place and some people told us there wasn’t enough to keep them occupied or stimulated.

People received enough to eat and drink and could request this anytime. People’s nutritional needs were met. However, the mealtime experience was sometimes chaotic and disorganised within the nursing and residential area of the home.

The CQC is required to monitor the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and report on what we find. People told us they had been involved in the planning of their care although this had not been consistently documented. People had not always formally given their consent to receive care and support although staff always gained consent before assisting people. People’s capacity to make decisions had not always been assessed. Where best interests decisions had been made on behalf of people who lacked capacity, these had been recorded following appropriate consultation with others. The service had made appropriate applications to the supervisory body for consideration of depriving a number of people of their liberty.

The service had completed recruitment checks to ensure that those that were employed were safe to work with older people. However, there wasn’t always enough staff to meet people’s needs. People told us they sometimes had to wait for assistance.

Although staff demonstrated the appropriate skills and knowledge to care for the people they supported, they had not been regularly or consistently trained. Staff had mixed views on whether they felt supported in their roles and supervision sessions had not been completed on a regular basis.

People told us staff were kind, caring and respectful. However, there were two occasions during our inspection where people became distressed and staff did not provide timely reassurance and comfort. We saw that staff spoke over one person on another occasion.

People’s dignity and privacy was maintained and they received choice in their day to day living. However, people’s independence was not always promoted.

People’s needs had been identified, assessed and reviewed on a regular basis. Their care plans were individual to them and accurate. Staff had enough information to be able to care for the people they supported. However, people did not always have care plans in place to support them with their specific medical needs although they had access to a variety of healthcare professionals.

There was a new management team in place and people had mixed opinions on the visibility and approachability of them. Some staff did not feel they were supportive.

Regular meetings had taken place to give people the opportunity to make suggestions and feedback on the service. The service had sent out questionnaires to gain people’s opinions and any concerns raised with the service had been fully investigated and addressed.

Below is a summary of what we found. The summary describes what staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

At our previous inspection carried out on 11 April 2014, we found that there were insufficient numbers of suitably qualified, skilled and experienced staff employed to effectively meet service user's assessed needs. Adequate staffing levels were not being maintained and staff absences were not being covered. Staff rotas covering the period from 31 March 2014 to 13 April 2014 had shown that unplanned absences had left the service short of care staff on 11 out of the 14 days.

During this inspection, we gathered evidence by speaking with staff, observing care and support being provided to people in communal areas of the home and we obtained copies of staff rotas covering the period 19 May 2014 to 08 June 2014.

The staff rotas showed that staffing levels had been maintained to an adequate level throughout the three week period apart from two occasions when unplanned absences had occurred. We were told that three staff had been recruited and had started their employment since our last visit, with the recruitment programme continuing into the future. This was to ensure that sufficient staff were available to cover all shifts and any absences.

Our observations showed that there were sufficient staff on duty to provide care and support to people. People were being assisted by staff in a calm and unhurried way. People using the service were seen chatting with staff and they appeared relaxed and cheerful. Staff spoke kindly and politely to people and responded appropriately to what was being said to them.

This is a summary of our findings. If you would like to see the evidence supporting this summary please read the full report.

Is the service safe?

The staff that we spoke to understood the procedures they needed to follow to ensure that people were safe. They were able to describe the various ways that people might experience abuse and the steps they would take if they had concerns that abuse was occurring.

We inspected the staff rotas which showed that there were not always sufficient numbers of staff on duty to safely meet the needs of people throughout the day. Staff were receiving training that was appropriate to their role and there was a training plan in place.

There were systems in place to learn from events such as accidents and complaints. Procedures were in place for dealing with emergencies.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to staffing.

Is the service effective?

People's health care needs were assessed but they had not signed to show they were involved in writing their care plans. Health and risk assessments identified individual care needs. People were supported to be as independent as possible. One person told us, 'Staff remind me to do things then I do them myself.'

People told us they liked living at Walsham Grange and that staff were kind and caring. Staff explained how they were able to communicate with people who were living with dementia and were not able to express themselves verbally.

Is the service caring?

People were supported by kind and attentive staff. All staff showed respect and encouraged people to be as independent as possible. One person said, 'The staff are good and help me.' Another person told us, 'I can get up when I want and carers help me to get washed and dressed.' People were relaxed in the company of staff and interactions were appropriate.

People told us they could spend their day where and with whom they pleased and staff assisted them to do this. Visitors were seen at the home throughout the day and were greeted in a friendly and welcoming manner by staff.

Is the service responsive?

People knew how to make a complaint if they were unhappy. The complaints process was displayed in the entrance hall. Where shortfalls or concerns were raised these were addressed.

People's needs were assessed and reviewed on a monthly basis. Where changes occurred, the service referred to health professionals for advice and guidance. We spoke with a visiting health professional who described the link worker as co-operative.

Is the service well led?

The service worked well with other agencies and services to make sure people received their care in a joined up way.

There were quality monitoring systems in place although they were not routinely being signed when completed. Care records were assessed and reviewed each month by senior staff. Audits of the environment were taking place regularly and these records were up to date and showed that remedial action was taken where shortfalls were identified.

Staff were clear about their roles and responsibilities. They spoke of how they worked as a team with the needs of the person central to the work they do.