Grasmere Lodge

Updated 16 June 2022

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

One inspector carried out the inspection.

Service and service type

Grasmere Lodge is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. Grasmere Lodge is a care home without nursing. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

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. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all this information to plan our inspection.

During the inspection

We spoke with six people who used the service and a relative about their experience of the care provided. We spoke with the registered manager, a senior carer and two care staff. We also contacted the nominated individual who provided information about the senior management team's oversight and governance arrangements. We reviewed three people’s care records, medicine administration records, two staff files and a variety of management and quality assurance records.

Updated 16 June 2022

About the service

Grasmere Lodge is a care home that provides accommodation and personal care for a maximum of 20 people with mental health needs or associated conditions. The service consists of two conjoined houses in a terrace street. At the time of this inspection 15 people were living at the service.

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

The senior management team oversight of the operation of the service needed improvement. The audit tools they used were very basic and did not allow for full scrutiny and critical review. Since the pandemic the management team had infrequently visited the service. The nominated individual stated this was because the service had Covid-19 outbreaks for six out of 25 months but it was unclear why this precluded visiting at other times.

The nominated individual told us they were aware work was needed to repair parts of the building but this had been delayed. They could not say when this work would be completed.

Risk assessments did not always cover pertinent issues or set out the actions needed to keep people safe. Some people smoked in their bedrooms and would not leave the room when the fire alarm sounded. Individual fire risk assessments had not considered issues around the fire integrity of the bedrooms. The provider confirmed they would explore improvements, which could be made fire risk management in the service.

Recruitment practices needed to be improved as items such as full employment histories, interview questionnaires, current photographs and references which matched the people named on the application form were missing.

The nominated individual confirmed none of the senior management team’s audits had led to the development of action plans. The governance system had not picked up issues despite there being areas for improvements. such as the repairs to the building, improving care records and staff files. No refurbishment plan was in place which meant the registered manager could not know about or plan for any works.

People felt safe. They commented on how staff were able to provide kind and compassionate care. People and relatives told us they had a positive relationship with the registered manager and staff. The registered manager and staff team had worked hard to maintain good working relationships with health and social care professionals. These relationships had supported them to deliver effective care and support.

There were enough staff on duty. Medicine management was effective. Incident monitoring records showed staff reviewed accidents and identified were lessons could be learnt. Staff adhered to COVID regulations and procedures.

Rating at last inspection

The last rating for this service was good (published 23 November 2018).

Why we inspected

We undertook this inspection as part of a random selection of services which have had a recent Direct Monitoring Approach (DMA) assessment where no further action was needed to seek assurance about this decision and to identify learning about the DMA process.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has remained requires improvement. This is based on the findings at this inspection.

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 coronavirus and other infection outbreaks effectively.

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

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified a breach in relation to the provider oversight of the service. Please see the action we have told the provider to take at the end of this report.

Follow up

We will continue to monitor information we receive about the service and we will continue to work with partner agencies. We will also request a specific action plan to understand what the provider will do immediately to ensure the service is safe. We will work alongside the provider and the local authority to closely monitor the service. We will return to visit in line with our re-inspection programme. If we receive any concerning information we may inspect sooner.