Windermere Grange Care Home

Updated 24 February 2024

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.

Inspection team

The inspection team consisted of 2 inspectors, a Pharmacist Specialist and 2 Experts by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Windermere Grange Care home 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. Windermere Grange Care home is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

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 a registered manager in post.

Notice of inspection

The inspection was unannounced.

What we did before the inspection

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 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 all this information to plan our inspection.

During the inspection

We spoke with 6 people who use the service and 14 family members. We spoke with 11 members of staff including the registered manager, deputy manager, unit manager, director of care and development and care staff. We also spoke with 2 visiting health professionals.

We reviewed a range of records. This included 10 people’s care records and multiple medication records. We looked at 2 staff files in relation to recruitment and staff supervision. We reviewed a variety of records relating to the management of the service, including audits and policies and procedures.

After the inspection

We continued to seek clarification from the registered manager to validate evidence found. We received feedback from 2 health professionals who work with the service.

Updated 24 February 2024

About the service

Windermere Grange Care Home is a residential care home. The service accommodates up to 64 people over two floors divided into four units. Two units provide care and support to older people, some of whom are living with dementia. People living with a learning disability are supported in the other two units. At the time of inspection 62 people were using the service.

People’s experience of the service and what we found:

Care plans provided guidance to ensure people received safe and responsive care and support. Risks were assessed and mitigated to keep people safe. However, where people may display distressed behaviours, the care plans we reviewed for older people lacked detail on what behaviours may be displayed and how these can be managed. Care plans were in place and contained person-centred information for people with a learning disability. However, care plans had not always been fully updated when changes occurred. Information in relation to people’s goals or outcome was not always clearly recorded. Daily records were generic and didn’t reflect the care needs identified in people’s care plans or the care provided. We spoke with the registered manager and Director of Care and Development about this. They assured us that the new electronic system they were introducing would address this.

Medicines were managed safely. Handwritten medicine administration records were not checked thoroughly, or counter signed to ensure accuracy; this is not in line with national guidance. Staff received training in medicines administration and competency assessments had been completed. Audit processes were in place, however work was needed to ensure the correct audit was completed at the right time and they were reviewed appropriately. We have made a recommendation about this.

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessment and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Right Support

People received care and support from staff who knew them well. People were supported to maintain and improve their independence. Risks in relation to people’s care and support were well managed to assist people to live their lives as they chose, and to access opportunities. There were enough staff to meet people’s identified hours of support, and this supported people to be able to access activities both socially and within their home.

Right Care

People received care and support from a staff team who knew their needs. One relative told us, “From what I can see they get the best care. She can call for assistance when she needs it.” The service worked with health and social care professionals to ensure they met people’s needs. A health care professional told us, “Staff know the residents really well. We come here knowing what issues there are and we always have a staff member accompany us during our visit. They follow up any guidance we put in place.”

Right Culture

People lived inclusive lives and were supported to take part in meaningful activities within the home and their local communities. One relative told us, “There are loads of activities going on. They do themed nights, and there are special foods from that country.” People and their relatives spoke positively about the service. Comments included, “I think the home is run well. The staff are always busy but still have time if you need to speak to them.”

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.

There was a positive culture within the service. Staff felt supported by the management team. Their comments included that the management team were visible and approachable, and they could discuss concerns and share ideas.

The service worked in partnership with other social and health care professionals. Feedback from health professionals was positive and included the following comments: “Out of all the care homes we deal with, it is very organised. We come here knowing what the issues are. They send a list of who needs seeing on the day. All information is accurate. They are not resistant to change or our service input. They will follow up any guidance we put in place.”

Systems were in place to monitor the quality of the service. However, there are some improvements required with the oversight of accidents and incidents. The registered manager understood their responsibility to follow the duty of candour and to be honest and open when something went wrong.

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 24 February 2020).

Why we inspected

The inspection was prompted in part due to concerns received about care planning, recording of accidents and incidents and staffing. A decision was made for us to inspect and examine those risks. We found no evidence during this inspection that people were at risk of harm from this concern.

We undertook a focused inspection to review the key questions of safe, responsive and well-led only. For those key question not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

You can read the report from our last comprehensive inspection by selecting the ‘All inspection reports and timeline’ link for Windermere Grange Care Home on our website at www.cqc.org.uk.

Recommendations

We have made a recommendation about the recording of some medicines. We have made a second recommendation about the provider ensuring care plans and daily records reflect the care needs for each person using the service.

Follow Up

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