28 April 2022
During an inspection looking at part of 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.