Elworth Grange

Updated 5 September 2023

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 Health and Social Care Act 2008.

As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was carried out by 1 Inspector.

Service and service type

Elworth Grange is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Elworth Grange is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was not a registered manager in post. A new manager had been in post for 3 months and had applied to register. We are currently assessing this application.

Notice of inspection

This inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 5 people who used the service about their experience of the care provided as well as 5 relatives. We spoke with 10 members of staff including the locality manager, registered manager, deputy manager, senior care workers, care workers and ancillary staff. We reviewed a range of records. This included 6 people's care records, risk assessments and medication records. We looked at 4 staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

Updated 5 September 2023

About the service

Elworth Grange is a residential care home supporting up to 66 people with a variety of needs, including dementia. Accommodation is purpose built and is provided across three floors, consisting of individual bedrooms with en-suite facilities and access to a range of communal areas. At the time of our inspection there were 50 people using the service.

Peoples experience of using the service had what we found

People were happy with the care they received. One person’s account of their experiences raised an issue wheret they felt some staff did not always take their specific communication needs and style into account. This combined with training for staff in effective communication is raised as a recommendation in this report.

People felt safe and happy with the approach of the staff team. The service had sent key information to the local authority relating to care concerns each month. A safeguarding referral had been made following information received and this is currently under consideration by safeguarding teams.

Risk assessments were in place relating to the hazards faced by people in their daily lives and had been taken into account. These assessments extended to checks of equipment safety and other equipment used by people.

Staffing levels met the needs of people with observations made of staff responding to people promptly. People we spoke with confirmed there were enough staff. The staffing compliment had relied on agency staff, but new staff had been recruited appropriately.

The environment remained clean and hygienic throughout.

The manager of the service had been appointed prior to the inspection. While information on the deregistration of the previous manager had been received, the provider had not informed us of management arrangements. This was done retrospectively.

Robust quality assurance systems were in place and people living at Elworth, their relatives and staff had the chance to express their views.

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. While arrangements for ensuring people had deprivation of liberty safeguards in place to protect them; one person’s DoLS had expired and had lapsed for a short time. We have raised this as a recommendation in this report for the provider to improve oversight of DoLS applications.

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 13 January 2022) a breach in governance of the service was identified. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

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. 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 changed from Requires Improvement to Good based on the findings of this inspection. You can read the report from our last inspection, by selecting the ‘all reports’ link for Elworth 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.