CQC report explained · a residential care home
What the CQC found at Priory Grange Care Home Limited
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff to meet people's needs, safer care records, safe medicines management and improved infection control. Staff understood safeguarding procedures and risks linked to people's care.
- Effective?
- Good
- This key question was not inspected during this focused visit. The report says the previous rating was used to calculate the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused visit. The report says the previous rating was used to calculate the overall rating.
- Responsive?
- Good
- This key question was not inspected during this focused visit. The report says the previous rating was used to calculate the overall rating.
- Well-led?
- Good
- Inspectors found stronger quality checks, better oversight and an open culture. People, relatives and staff said the manager was approachable and that concerns were dealt with.
What inspectors found, April 2023
Priory Grange Care Home Limited is rated Good and no longer in special measures; inspectors found safer care, improved records and stronger management.
This was an unannounced focused inspection on 12 April 2023. One inspector spoke with people, relatives and staff, and reviewed care records, medicines records, staff files and management information.
The home was rated Good for Safe and Well-led. Inspectors found enough staff, safer medicines management, better care records, improved infection control and effective safeguarding arrangements. People and relatives said they felt safe and well supported.
The previous rating was Requires Improvement, and the home had been in Special Measures since June 2021. Inspectors found the provider had made enough improvements to meet the regulations, so the home was no longer in Special Measures.
Enough staff
Staffing levels had improved, including at night. Inspectors saw people receiving help without delays.
“Appropriate staffing levels were in place to meet the needs of people in the service.” from the report
Safer records
Care records gave staff information about people's needs, risks, preferences and choices.
“Care records contained information about people's needs and risks.” from the report
Medicines managed safely
Staff had medicines training and competency checks. Audits were being used to monitor medicines management.
“Audits had been used effectively to help monitor and make sure medicines were managed safely.” from the report
Open management
Inspectors found better oversight of quality and safety. People and relatives said they could raise concerns with the manager.
“The registered manager had an open-door policy and people and staff said they could go to the manager any time if they needed.” from the report
Inspectors raised no specific concerns in this report.
- 01How are you maintaining the improved night staffing levels, and how do you check they still meet each person's needs?
- 02Can you show us recent audits of medicines records and explain what action is taken if an error is found?
- 03How do you keep care records up to date when people's needs, preferences or risks change?
- 04What were the ratings for Effective, Caring and Responsive at the last comprehensive inspection, and what improvements have been made in those areas since then?
This was a focused inspection of Safe and Well-led, with infection prevention and control also considered; the other ratings were carried forward from the last comprehensive inspection. This explanation was written from the published report of 28 April 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, September 2021
Rated Requires Improvement and still in special measures; the well-led rating was Inadequate, with safety risks and weak oversight still needing action.
This was an unannounced focused inspection on 14 July 2021, followed by an announced visit on 19 July 2021. Inspectors spoke with people living at the home, relatives, staff and a visiting professional. They also checked care, medicines, staffing, recruitment and management records.
The home had improved since its previous Inadequate rating, including in medicines management and some parts of the building. However, inspectors found risks from night staffing, cleanliness, window restrictors and legionella in the water system. Some concerns were dealt with after the inspection, but the systems for finding problems were not yet reliable.
The overall rating improved from Inadequate to Requires Improvement. Safe was rated Requires Improvement. Well-led remained Inadequate. The home remained in special measures because it had an Inadequate rating for a key question at two consecutive inspections.
Kind, person-centred care
People and relatives generally spoke positively about the care. Staff were described as kind and understanding.
“The staff are nice, kind, and understand me.” from the report
Improved medicines support
Staff had medicines training and their competence was checked. People generally said medicines were given safely and on time.
“People gave generally positive feedback about the support provided to take their prescribed medicines.” from the report
Learning from incidents
The manager had introduced a system to record and review accidents and incidents, including actions to reduce the chance of repetition.
“Records of accidents and incidents showed what had happened and how staff had responded, including the actions taken to try and make sure a similar thing did not happen again.” from the report
Safeguarding awareness
Staff had training and understood their responsibility to identify and report safeguarding concerns.
“Staff completed training and understood their responsibility to identify and report any safeguarding concerns to help keep people safe.” from the report
Night staffing
seriousThere were occasions when only two staff supported about 30 people at night, including people needing two staff for care. The home had not properly checked whether this was safe or whether people could be evacuated at night.
“People were at increased risk of harm as the provider and registered manager had not taken adequate steps to make sure staffing levels at night were safe.” from the report
Cleanliness and maintenance
needs fixingSome areas were unclean, cleaning staff were not always sufficient, and communal bathrooms and toilets still needed renovation.
“Enough cleaning staff were not always deployed to maintain consistent standards of cleanliness.” from the report
Weak oversight
seriousAudits had not identified the problems found by inspectors. Management responded to feedback, but systems were not yet embedded or effective.
“The provider and registered manager completed a range of audits and checks to monitor the service and drive improvements, but these systems were not yet fully embedded and effective.” from the report
Medicine records
minorMedicine records had minor gaps, including unclear reasons when medicines were not given. There was also no clear audit trail for unused medicines returned to the pharmacy.
“There were minor gaps on people's medicine administration and topical administration records; codes had not always been used appropriately to clearly explain why a medicine had not been administered.” from the report
- 01How many staff are now on duty at night, and how have you checked that this is enough for the current residents' needs?
- 02Have you completed suitable night-time fire drills and simulated evacuations, and what did they show?
- 03Have window restrictors now been fitted everywhere needed, and how are they checked?
- 04What action has been taken to manage legionella risks in the water system, and when was this last reviewed?
- 05How are your audits now checking staffing, cleanliness, building safety and medicine records before problems arise?
This was a focused inspection of Safe and Well-led, including infection prevention and control; the other key question ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 23 September 2021 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 Priory Grange Care Home Limited
6 rated inspections over 8 years: the service has held its Good rating throughout.
- April 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Priory Grange Care Home Limited →
- September 2021Requires improvementup from InadequateSafe: Requires improvementWell-led: Inadequate
Read what inspectors found at Priory Grange Care Home Limited →
- June 2021Inadequatedown from GoodSafe: InadequateWell-led: Inadequate
- June 2018Goodup from Requires improvementSafe: GoodWell-led: Requires improvement
- January 2017Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- May 2011
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 3 February 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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