Grafton Manor

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

At the last inspection the provider was in breach of regulation 17 in relation to ineffective quality, safety and leadership of the service. 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 new and existing audits were fully embedded and effective ongoing monitoring of people’s care and associated monitoring records, mental capacity assessments, oversight of medicines, incidents, safeguarding and physical interventions, staff training and health and safety requirements. The interim management team carried out regular audits and had oversight of risks and safety within the service. The provider was actively recruiting a new management team.

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 Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider had implemented systems and processes to monitor all aspects of quality and safety in the service. These included systems used to ensure staff were supported and trained to meet people’s care and health needs and identifying trends from incidents and accidents and action taken to prevent further recurrences and promoted people’s safety and wellbeing. Some audits required strengthening, scrutiny and time to fully embed. For example, the medicine audit had not been completed fully and outbuildings were not included in the premises audits. The manager assured us these would be rectified. Provider visits were used to monitor the progress of ensure improvements. The improvement plan showed a number of actions remain in progress. These included the refurbishment and decoration, review of people’s care plans and risks assessment, and providing person-centred care in relation to activities and aspirations. Staff felt confident to approach the peripatetic manager if they had any concerns and felt they had people at the heart of the service. Staff told us at they received were supervisions and kept up to date through regular meetings, for instance they discussed the whistleblowing policy recently. Systems were in place to ensure staff received regular training updates and communication between the manager and staff had improved.

The service does not have a registered manager. The service had an interim management team. They included a peripatetic manager, a clinical care lead and an operations manager whilst a suitable manager was recruited. During this assessment the peripatetic manager was responsive to feedback and took action to mitigate risks in relation to the premises, medicines, feedback from relatives and provided required information.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.