Wentworth Grange

Updated 6 December 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 Act.

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

The inspection was carried out by an inspector, a medicines inspector and an Expert 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

Wentworth Grange is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. 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 a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service. 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 of this information to plan our inspection.

During the inspection

We spoke with 5 people, 5 relatives and 10 staff, including the registered manager, two assistant managers, clinical lead, senior carers and other care staff. We contacted 5 external professionals via telephone and email.

We observed interactions between staff and people, including at lunchtime. We reviewed a range of records. This included 6 people's care records and medicines records. We reviewed a variety of records relating to the management of the service, including policies and procedures, investigations, training records.

Updated 6 December 2023

About the service

Wentworth Grange is registered to provide accommodation, nursing and personal care to a maximum of 51 older people, including people who live with dementia. The service was made up of 2 distinct units, with shared outdoor grounds. At the time of the inspection there were 46 people living at the home.

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

There were a lack of coherent systems and processes for identifying patterns and trends. Audits had been completed, but not rigorously or systematically. Opportunities for practice improvement had therefore been missed.

Some aspects of medicines administration were not always in line with current good practice. Some records needed improvement.

The provider had not always conducted internal investigations sufficiently, or with demonstrable lessons learned to ensure that future recurrences would be avoided.

The culture was not always open, with delays in sharing information with relevant agencies and a lack of clear lessons learned after incidents. We have made a recommendation about this.

There were some aspects of good medicines management and sound knowledge of people’s needs demonstrated by staff. Staff were trained, supervised and had their competence regularly assessed.

Care planning was person-centred and detailed. Staff demonstrated a good understanding of the risks people faced and how to reduce them.

People were supported to have maximum choice and control of their lives and to live in the least restrictive way possible and in their best interests; policies and systems in the service supported this practice. The provider had not always made the relevant notifications to CQC in a timely fashion. We have made a recommendation about this.

People felt safe and supported. Staff regularly checked on people’s wellbeing. Relatives told us they had confidence in the ability of staff to look after their loved ones in a safe way.

The environment was clean and well maintained. Areas of the home had been recently refurbished to a high standard.

Staff were recruited safely. Staff received supervisions and felt able to raise concerns where they had them.

The provider had relevant policies and procedures in place to help reduce the risk of abuse. Staff reacted promptly to individual incidents and concerns, but there was a lack of meaningful oversight and lessons learned. Some policies needed review, or there was a lack of review of some policies. The provider had not always stayed abreast of good practice. We have made a recommendation about this.

The provider worked with external health and social care professionals to ensure people received the right care. The provider did not always share information in a timely way.

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 6 February 2018).

Why we inspected

This inspection was prompted by a review of the information we held about this service. We undertook a focused inspection to review the key questions of safe and well-led only.

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 good to requires improvement based on the findings of this inspection.

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

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

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

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.

Enforcement and Recommendations

We have identified a breach of regulations in relation to good governance. We have made recommendations regarding the provider’s understanding of notifications to CQC, the provider’s awareness of best practice and the provider’s openness.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.