Grafton Manor

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

At the last inspection the provider was in breach of regulation 12, Safe care and treatment, in relation to managing risks associated to people’s health conditions. We imposed conditions on the provider’s registration. At this assessment the provider had made enough improvements and was no longer in breach of this regulation. Conditions remain in place to ensure safe clinical oversight and monitoring of people’s health conditions. Although there were sufficient numbers of trained staff to meet people’s care needs, where people wanted to take part in activities, staff had not been allocated to ensure all the activities could take place. There was ongoing refurbishment of the service. The interim management team were new to the service and not fully aware of the premises including the outbuildings. We found some areas of the service were not safe and the manager took action to rectify this. People did not always received their medicines as prescribed. This was raised with the manager after the on-site assessment. There was no evidence of any harm caused to people’s health. The manager put in place measures that ensured staff administered medicines as prescribed and increased the monitoring and checks carried out.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

People had access to the equipment they needed. Equipment used for moving and handling was checked and serviced regularly.

There was ongoing refurbishment of the service. During the on-site assessment we identified risks with the COSSH room, unoccupied bedrooms and outbuildings that were accessible to people. The manager took action to ensure those rooms were locked and they also ordered a replacement microwave. Regular servicing and maintenance checks including fire safety were carried out to ensure fire and health and safety requirements were met. The provider action plan was monitored to check the progress of improvements. Although issues we found had not been identified through the audits the manager assured us the identified areas would be monitored.

People felt safe at the service. People’s relatives told us their family member lived in a clean and tidy environment and they had access to the equipment they needed.

Staff showed good knowledge of the support people required to meet people’s needs and promote their safety. Staff were trained to use equipment required to promote people’s safety.

Staff told us there were enough staff to meet people's needs, especially since the new activities person had been employed.

Staffing levels were maintained and regular agency staff used where there were shortfalls. The provider had allocated a staff member to cook meals for which they were trained and felt confident to do so. The manager told us as occupancy increased a cook would be employed to support the role in the kitchen. The provider had recently recruited new care staff and an activity staff to improve people’s quality of care. Staff received training and support for their roles. Staff competency was checked and they received regular updates on current practice.

People and thier relatives told us staffing was “ok” and there were regular staff and the same agency staff.

During our on-site assessment we saw a person could not go out for a walk because agency staff did not know them well enough.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

Medicines procedures were in place but were not fully followed by staff. Regular medicine audits had not been fully completed; there was a risk that issues we had identified would not have been identified in the planned audits. Following our feedback, the manager demonstrated the actions they had taken to prevent recurrence.

Staff training and their competency was up to date. Staff knowledge and practice had improved in the management of diabetes.

People did not always receive their medicines as prescribed. This was raised with the manager. Following the on-site assessment the manager assured us no one was harmed and staff were reminded to ensure medicines were administered as prescribed.