Walsham Grange

Updated 21 July 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 an inspector, a member of CQC’s medicines team 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

Walsham 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. Walsham 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.

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 not a registered manager in post.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 22 June 2023 and ended on 6 July 2023. We visited the location’s service on 22 June 2023.

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 4 people who used the service and 17 relatives. We spoke with 6 staff including the regional manager, deputy manager, regional deputy manager and care staff.

We reviewed a range of records. This included 7 people’s care records and 19 medication records. We looked at 4 staff files in relation to recruitment, training, and supervision. A variety of records relating to the management of the service including audits, policies and procedures were reviewed.

Updated 21 July 2023

About the service

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.