CQC report explained · a residential care home
What the CQC found at Enderby Grange
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found sufficient trained staff, safe recruitment, safe medicines management, risk assessments and effective infection control. They also found that people generally felt safe.
- Effective?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward when calculating the overall rating.
- Caring?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward when calculating the overall rating.
- Responsive?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward when calculating the overall rating.
- Well-led?
- Requires improvement
- Communication about people's health, wellbeing and care needs was not always consistent or timely. Management monitoring systems were in place, but some reports did not initially include audit outcomes and required improvement actions.
What inspectors found, June 2023
Rated Good overall; inspectors found safe care, but the home was not always well-led because communication and some monitoring needed improvement.
This was an unannounced focused inspection on 11 and 15 May 2023. Inspectors looked only at Safe and Well-led, after concerns about medicines, infection control and risk management. They spoke with people, relatives, staff and professionals, and checked care, staff and management records.
The home was rated Good for Safe. Inspectors found enough trained staff, safe recruitment, safe medicines systems, risk assessments and good infection control. People generally said they felt safe and received kind, timely support.
Well-led was rated Requires Improvement. Communication was not always consistent, so staff and visiting professionals did not always have up-to-date information about people's health and care needs. Some management monitoring reports also did not initially show audit outcomes or the actions needed to improve.
The overall rating stayed Good because the other three question ratings were carried over from the previous inspection. The previous overall rating was also Good.
Safe staffing
Inspectors found enough staff with suitable training and skills. People and relatives said staff usually responded promptly when help was needed.
“There were sufficient staff with the necessary training, skills and competence to promote people's safety and wellbeing.” from the report
Medicines
Medicines were stored, given and recorded safely. Staff were trained and their competence was checked regularly.
“People received their medicines as prescribed and were administered by staff trained in the management of medicine who had their competency regularly assessed.” from the report
Risk management
Risks were assessed and reviewed. The home used measures such as sensor mats and increased observation to reduce the risk of falls.
“Potential risks to people were assessed and kept under review to promote their safety.” from the report
Clean environment
Inspectors were assured about infection prevention and control. People and relatives described the home as clean.
“We were assured that the provider was promoting safety through the layout and hygiene practices of the premises.” from the report
Listening to feedback
People and relatives could raise concerns and give feedback through surveys and meetings. The report gave examples of changes to menus and activities following feedback.
“Action was taken in response to people's feedback.” from the report
Communication between staff
needs fixingStaff and visiting professionals said information about people's health, wellbeing and care needs was not always shared consistently or promptly.
“Many staff told us improvements were needed to ensure consistent and timely information was shared in relation to people's care.” from the report
Management monitoring
needs fixingA monthly management report did not initially include audit results or the actions needed to improve. The report template was changed during the inspection.
“However, the report did not include the outcome of audits and the actions required to bring about improvement.” from the report
Mixed communication with relatives
needs fixingMost relatives said management listened and acted, but some reported that communication was not always good and that concerns were not always addressed.
“A family member told us communication between themselves and staff was not always the best, which included the management team not addressing concerns raised.” from the report
- 01How do you make sure every staff member has up-to-date information about a person's health, wellbeing and care needs?
- 02What changes have you made since the inspection to improve communication between staff and visiting professionals?
- 03How do your audits now record the results and the actions needed when improvements are found?
- 04How are falls risks monitored, especially when people are in communal areas?
- 05How do you check that concerns raised by relatives are recorded, answered and followed up?
This was a focused inspection of Safe and Well-led only; the Effective, Caring and Responsive ratings were carried over from the previous inspection. This explanation was written from the published report of 16 June 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, May 2022
Rated Good overall; inspectors found safe, kind and personalised care, with some end of life plans still needing more detail.
This was an unannounced inspection. One inspector visited the home and an Expert by Experience contacted relatives. Inspectors spoke with people, relatives and staff, and reviewed care, medicines, recruitment and management records.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough trained staff, safe medicines practice, personalised care and good support for people's choices, health needs, relationships and activities.
The home had improved since its previous Requires Improvement rating, published in January 2020. The provider was no longer in breach of the regulations identified at that inspection. Inspectors noted that some care plans did not contain enough information about end of life care.
Enough staff
Inspectors found enough experienced and qualified staff to meet people's needs safely.
“There were enough experienced and qualified staff to safely meet people's needs.” from the report
Personalised care
Care plans reflected people's needs, abilities, risks and preferences. Staff knew people well and supported them as individuals.
“People's care plans were detailed and individualised.” from the report
Kind and respectful staff
People and relatives spoke positively about staff. Inspectors observed respectful communication, reassurance and support for privacy and dignity.
“Staff supported people in a respectful and caring way.” from the report
Activities and relationships
The home supported people to stay in contact with relatives and take part in activities suited to their interests.
“Staff supported people to pursue their interests and take part in activities.” from the report
Listening and improving
The home gathered feedback from people, relatives and staff and used it in action plans and service improvements.
“Quality monitoring was effective, people were asked to provide feedback and this was used to drive improvements.” from the report
End of life plans
needs fixingCare plans did not always explain people's end of life wishes and support needs. The manager accepted that this was important and discussed how to improve it.
“Care plans did not always include information on end of life care and support.” from the report
- 01How will you make sure every person's end of life wishes and support needs are recorded in their care plan?
- 02How do you check that staffing levels remain sufficient for the current needs of residents?
- 03How are residents' preferred activities recorded and reviewed when their interests or abilities change?
- 04How are relatives involved in best interests decisions when a person cannot make a particular decision?
- 05How do you check that changes in people's needs are communicated to every staff member?
This unannounced inspection covered all five CQC key questions and included infection prevention and control checks; the visit took place on 8 March 2022, with inspection activity ending on 9 March 2022. This explanation was written from the published report of 20 May 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Enderby Grange
6 rated inspections over 8 years: the service has held its Good rating throughout.
- June 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2022GoodSafe: GoodWell-led: Good
- January 2021Inspected but not ratedSafe: Inspected but not rated
- January 2020Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- October 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 5 November 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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At least 100 live-in carers within about an hour of Leicestershire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,260 a week. 82 can care for a couple. 12 years' experience on average.
“If you bump into her in the night on her way to the bathroom she will still inquire how you are and if everything is alright.”
“Together Earther and I supported her to die at home with great dignity and compassion and him to continue with life.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.