Deewater Grange

Updated 18 May 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

The inspection was carried out by one inspector a Specialist Advisor Nurse 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

Deewater 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. Deewater Grange is a care home with 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

This inspection was unannounced.

What we did before the 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 7 people who used the service and 8 people's relatives to gain their feedback about the service. We spoke with 14 staff including, registered manager, deputy manager, area manager, 3 nurses, activity co-ordinator, 3 team leaders, support workers and auxiliary staff. We reviewed a range of records. This included 6 people's care records and samples of medicine records and daily and associated records of their care including care plans and risk assessments. We looked at 4 staff records and a variety of records relating to the management of the service, including audits and procedures. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

Updated 18 May 2023

About the service

Deewater Grange is a care home providing accommodation, personal and nursing care for up to 58 older people in one adapted building. The service supports younger and older adults living with physical disabilities and dementia. The service has separate wings supporting residential dementia care, nursing dementia care and general nursing. All of people’s rooms have en-suite facilities. Communal bathing and toilet facilities are also located throughout the care home. At the time of our inspection, there were 51 people using the service.

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

Recruitment procedures were robust and demonstrated staff were safely recruited. Staff completed an induction and undertook shadow shifts to support their understanding of the role and the people they supported.

People were protected from the risk of abuse. Safeguarding policies and procedures were in place. Staff had received training and understood how to keep people safe. They knew who to report to if they had any concerns.

People’s needs had been assessed prior to living at the service. Individual risk assessments were in place to highlight areas of risk and give clear guidance to staff about how to minimise any risks identified. People living with dementia that may use behaviour to express a feeling had clear support plans and risk assessments in place where needed.

The management and administration of medicines was robust with clear procedures in place. The management of people's 'as required' medicines was safe with clear and consistent records were in place. Medicines were managed by trained and competent staff.

The staff and management team had developed positive relationships with people and their relatives. They had an excellent understanding of how to meet people’s individual needs and fully understood their routines and preferences.

Safety checks of the premises and equipment had been undertaken. All areas of the service were clean and well maintained. People had personal emergency evacuation plans (PEEPs) in place.

There were effective systems in place to monitor the quality of the care provided. The management team identified and promptly addressed any areas identified for development and improvement.

The staff and management team worked closely with health and social care professionals to ensure the best outcomes for people.

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.

Rating at last inspection

The last rating for this service was good [Published 10 September 2022].

Why we inspected

We received concerns in relation to staff skills, the management of behaviours that may challenge and the providers assessment process. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We found no evidence during this inspection that people were at risk of harm from this concern.

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

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.

Follow up

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