CQC report explained · a nursing home
What the CQC found at Hallmark Anisha Grange Luxury Care Home
Rated Outstanding: inspectors found the home performing exceptionally well.
- Safe?
- Good
- People felt safe and staffing had improved, with the home fully staffed and no longer relying on agency workers. However, there were isolated medicines practice and record-keeping issues, and two incidents had not followed robust processes.
- Effective?
- Good
- Staff had good training, induction and supervision. People received support with food, drink and healthcare, and staff worked with professionals to improve outcomes, including reducing some dementia medicines.
- Caring?
- Good
- People and relatives described staff as kind, friendly and respectful. Staff involved people in decisions, protected privacy and promoted independence.
- Responsive?
- Outstanding
- Care was tailored around people's histories, preferences and routines. The home offered a wide range of activities, helped people maintain relationships and had an open approach to complaints and end of life care.
- Well-led?
- Outstanding
- Inspectors found exceptional leadership, a caring and inclusive culture, strong staff morale and regular checks on quality and safety. People, relatives and staff were actively involved in improving the home.
What inspectors found, April 2020
Rated Outstanding; inspectors found kind, personalised care and exceptional leadership, with some medicines and incident records needing attention.
This was an unannounced inspection on 22 and 23 January 2020, with further information received on 5 February. Inspectors spoke with 19 people, four relatives, staff and health professionals. They observed care and reviewed care, medicine, staffing and management records.
The home was rated Outstanding overall. Safe, Effective and Caring were rated Good. Responsive and Well-led improved from Good to Outstanding since the previous inspection in June 2017.
People said they felt safe, happy and listened to. Inspectors found regular staff, kind care, good training, personalised support and many activities. The home also had strong links with the local community and health professionals.
There were some shortfalls. Two incidents had not been managed through the home's robust processes, one staff member showed poor medicines practice, and medicine stock counts did not always match the electronic records. The manager acted on these issues and improvements were already being made.
Kind and respectful care
People and relatives consistently described staff as kind, friendly and respectful. Staff involved people in choices and supported their independence.
“I'd describe the staff as wonderful; they ask for my opinions about things and they listen, they never force me to do anything I don't want to do.” from the report
Personalised daily life
The home recorded people's interests, routines and life histories and used them to shape care. People had choice over daily routines and could continue activities that mattered to them.
“Personalised information about people's likes, dislikes, hobbies and interests and life history was recorded in people's care records and shared with staff” from the report
Activities and community links
Inspectors saw a broad programme of activities, including yoga and art. The home also helped people take part in community and intergenerational activities and reduced loneliness for people who could not leave their rooms.
“Considerable time and resources had been invested to ensure people enjoyed living at the service and were provided with lots of opportunities to live full and varied lives” from the report
Strong leadership and involvement
The management team was visible and approachable. People, relatives and staff were asked for feedback, and the home used meetings, audits and improvement projects to act on it.
“There was an extremely positive culture at Anisha Grange where people were placed at the heart of the service.” from the report
Medicine records did not always match
seriousSeveral medicine stock counts did not match the electronic administration records. This made it difficult to confirm whether people had received their medicines as prescribed, although audits had identified the issue and improvements were under way.
“Records showed there had been several occurrences where the medicine stock count did not match the number of medicines recorded on the EMAR system” from the report
Isolated poor medicines practice
seriousInspectors saw one example of poor medicines practice on the Primrose unit. The manager took action and said the staff member would receive further training.
“However, on Primrose unit we found an isolated incident of poor practice by a staff member.” from the report
Two incidents were not fully managed
needs fixingInspectors found two examples where the home's robust accident and incident processes had not been applied consistently. The manager was told and addressed the issue immediately.
“However, we did find two examples where robust processes had not been consistently applied.” from the report
- 01What changes were made to ensure medicine stock counts always match the electronic administration records?
- 02How do you now check that medicines are administered safely and recorded correctly on every unit?
- 03What were the two incidents where processes were not followed, and what was changed to prevent this happening again?
- 04How will my relative's personal routines, interests, communication needs and end of life wishes be recorded and reviewed?
- 05Which activities and one-to-one support would be available if my relative could not leave their room?
This was an unannounced inspection covering all five CQC questions, including care, premises, records, staff, medicines and management systems; further information received on 5 February was also considered. This explanation was written from the published report of 2 April 2020 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, July 2017
Rated Good; inspectors found much improved safe, kind and personalised care, with some areas still needing attention.
Inspectors visited without warning on 8 and 12 June 2017. They spoke with 21 people, eight family members and 13 care staff. They also observed care and reviewed care records, staff files, complaints, incidents and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safer risk checks, safe medicines practice and better support for people with complex needs.
People were treated with kindness and respect. Care plans were detailed and personalised. People were offered activities and choices, and families were welcomed. Complaints were listened to and used to improve the service.
The home had improved greatly since the previous inspection, when staffing, morale and management oversight were concerns. At this visit, the culture was more positive, although there had been several management changes and some improvements were still ongoing.
Improved safety
Risk checks had been redesigned and staff understood who needed monitoring, how often and what action to take. Inspectors also found enough staff to meet people's needs.
“The monitoring charts used by staff had been completely revised since our last inspection and were now easy and clear to follow.” from the report
Kind and respectful care
Staff focused on the person rather than just completing tasks. People were treated with dignity and had choices about their care.
“Staff focused on the person rather than the task in hand.” from the report
Personalised support
Care plans explained people's needs and preferences in detail. Activities and everyday support were adapted to people's interests.
“People's care was outlined in detailed support plans which provided staff with information to meet their needs.” from the report
Positive leadership
Inspectors found a more settled culture, better staff communication and stronger management oversight than at the previous inspection.
“The manager had helped transform the culture at the service.” from the report
Family involvement
Families were welcomed and encouraged to give feedback. The home responded to complaints and used them to improve care.
“Complaints were responded to well and led to improvement.” from the report
Use of agency staff
needs fixingSome agency staff were still being used while new staff were recruited. One person said temporary night staff did not always know residents or their preferences.
“I don't like having agency staff, the night staff are often agency and of course they don't know us, or how we like things done.” from the report
Dementia unit improvements
needs fixingSome bedroom door signs were missing and inspectors did not see memory boxes in use. The report said further improvement was needed in line with best practice.
“We did not observe any memory boxes in use, which we had previously been told were being set up.” from the report
Emergency plans
needs fixingOne person's fire evacuation plan did not give enough detail for a new or temporary staff member. The manager agreed to review the plans.
“We discussed this advice with the manager who agreed it was vague, especially if a person was being supported by a new or temporary member of staff who did not know them.” from the report
Management continuity
needs fixingThere had been several managers over a short period, and quality checks had been inconsistent. The report said the new manager was expected to bring greater consistency.
“There was some inconsistency due to the turnover in managers and input from different senior managers.” from the report
- 01How many agency staff are currently working here, especially at night, and how do you make sure they know each person's needs and preferences?
- 02What changes have been made to bedroom signs, memory boxes and other dementia support since this inspection?
- 03How are fire evacuation plans kept specific and clear for new or temporary staff?
- 04Is the manager now registered with the CQC, and how has management continuity been maintained?
- 05How can residents choose their meals on the day rather than ordering in advance?
This was an unannounced inspection covering the overall quality of the home and all five CQC questions, including speaking with people, families and staff, observing care and reviewing records. This explanation was written from the published report of 19 July 2017 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 Hallmark Anisha Grange Luxury Care Home
3 rated inspections over 4 years: the service has improved, from Requires improvement to Outstanding.
- April 2020Outstandingcurrent ratingup from GoodSafe: GoodEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Outstanding
Read what inspectors found at Hallmark Anisha Grange Luxury Care Home →
- July 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Hallmark Anisha Grange Luxury Care Home →
- September 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- September 2011
Registered with the Care Quality Commission on 13 September 2011.
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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Most charge £1,020 to £1,260 a week. 25 can care for a couple. 10 years' experience on average.
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