Grasmere Nursing Home

There was a registered manager in post who joined us throughout our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. They had been in post since October 2015.

At the last inspection on 20 July 2016 we identified one breach of Regulations associated with how the staff managed prescribed medicines. We found risk assessments was an area which required improvement as they did not always contain the necessary details and guidance needed to ensure risks to people were mitigated. We also identified care records failed to capture how best interest decisions had been made on behalf of people who lacked capacity to do so for themselves. Following the last inspection, the provider wrote to us to confirm that they had addressed these issues. At this visit, we found actions had been completed and the provider has now met all the legal requirements to ensure the home was safe and effective.

Significant improvements had been made to how medicines were managed. This included how medicines were stored and records of stock levels maintained. Homely remedies were administered to people as recommended and records of when they had been opened and administered were accurate. The registered manager had implemented guidance for ‘when required’ medicines. This included medicines used for pain relief. However, audits to monitor medicine systems were not always effective. This included where this guidance could be developed further. We have referred to this in the Well-led section of this report. In addition, there was a range of other health and safety audit processes to measure the overall quality of the service provided to people and to make improvements when needed.

Since our last inspection the registered manager had developed risk assessments to ensure risks to people’s health and welfare were minimised and consistency in care was provided. There were also detailed personalised mental capacity assessments on behalf of those who were assessed as lacking capacity to make specific decisions. The staff had worked in accordance with current legislation relating to the Mental Capacity Act 2005 and the Deprivation to Liberties Safeguards (DoLS).

People and their relatives told us their family members were safe at the home. Staff were trained in adult safeguarding procedures and knew what to do if they considered people were at risk from harm.

Staff knew people well and kind, caring relationships had been developed. People were treated with dignity and respect. Care plans reflected information relevant to each individual and their abilities, including people's communication and health needs. People were provided with a balanced diet, plenty of opportunities to eat and drink between meals and flexibility surrounding the support they needed. Staff were vigilant to changes in people's health needs and their support was reviewed when required. If people required input from other health and social care professionals, this was arranged.

People were offered activities to attend within the home. All complaints were treated seriously and were overseen by the registered manager. People and their relatives were provided opportunities to give their views about the care they received from the service. Some people chose to use these opportunities to become more involved with their care and treatment. Relatives were also encouraged to give their feedback on how they viewed the service. Staff understood their role and responsibilities and valued the support and training they were provided from the registered manager and other staff within their team.

The registered manager demonstrated a 'hands-on' approach and knew people well. They had embedded caring values throughout the home. The registered manager understood their responsibilities associated with being registered with the Commission.

The registered manager had been in post since October 2015 and was present throughout the inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People received their regular medications safely and as prescribed. However, stock balances were not maintained, so any discrepancies could not be identified and homely remedies had not always been recorded, so it was unclear if people had received them or not. Allergies were not recorded accurately on the medication administration record for two people, which meant they were at risk of being prescribed and administered medicines which could cause them harm. There was also a lack of guidance for staff regarding the administration of ‘as required’ medicines, which meant that there was a risk of medicines being given inappropriately. Dates of opening were not always recorded on liquid medications which had a limited shelf life, which meant that people were at risk of receiving out of date medicines. This meant that medicines were not always managed safely and was identified as a breach of the Health and Social care Act 2008 (Regulated Activities) Regulations 2014.

Individual risks were identified and assessed. However, guidance for staff lacked sufficient detail to manage these risks effectively. For example, one person had difficulty swallowing liquids. A Speech and Language Therapist (SALT) assessment recommended that one scoop of thickening agent per beaker would thicken fluids sufficiently for the person to swallow them safely. However this information was not incorporated into the care plan for this person. Another person was identified as prone to constipation. There was a stool chart in place and they were prescribed ‘as required’ laxatives. However, there was no clear guidance to staff regarding this person’s usual routine or when ‘as required’ medicines should be given. This meant that staff did not have all the information they needed to manage individual risks effectively and was identified as an area of practice that needs improvement.

Staff had received training and understood the principles of the Mental Capacity Act 2005 (MCA). There were detailed mental capacity assessments in place and where people lacked mental capacity to make some decisions there was clear guidance to staff regarding which decisions people could make for themselves and which they could not. However, where people were assessed as not having capacity it was not clear how or why decisions had been made on their behalf. This meant that decisions made in people’s best interests were not recorded in line with legal requirements and this was identified as an area that needs improvement.

On the day of inspection the dining room was shared with the hairdresser whose kit remained laid out over the lunchtime period. The registered manager told us this happened once a fortnight. One person was part way through having their hair done when lunch was served. This was not dignified experience for this person, nor was it hygienic or pleasant for others eating in the dining room, as there was also a strong smell of perming lotion and we have identified this as an area of practice that needs improvement.

The provider employed dedicated activities staff and there was a programme of activities and entertainment in place. Art and craft activities were held twice a week and entertainment and exercise sessions also took place. One member of staff was employed to deliver one to one activities to people who were at risk of social isolation and they told us how they spent time with people reminiscing or reading the newspaper. There was a garden party in June which was well attended and people were invited to plan further activities through discussion in residents meetings.

People told us they felt safe and that there were enough suitable staff to meet their needs. Call bells were answered promptly. One person said, “Oh yes, they always come very quickly and check what you need them to do for you.” There was a robust recruitment process in place to ensure that any staff employed were of good character and safe to work with people.

Environmental risks were well managed. There were health and safety and equipment checks in place and any repairs were attended to promptly. Accidents and incidents were recorded and monitored for trends with actions plans in place to reduce the risk of recurrence.

People were appreciative of their environment, they told us it was clean and they liked the décor.The environment was clean and well maintained with no malodours. Cleaning schedules were in place and waste was managed appropriately. There was an infection control champion and staff were trained in infection control and used personal protective equipment such as gloves and aprons appropriately.

Staff had the knowledge and skills to support people’s needs and were supported through regular supervision and appraisal with the registered manager. People told us they felt that staff were well trained and knew what they were doing.

People were supported to have sufficient to eat and drink. Special or modified diets were provided and people said that they enjoyed the food. Hot and cold drinks were offered throughout the day and fluid intake was monitored for those identified as at risk of dehydration or urinary tract infections.

Staff monitored people’s health and wellbeing and supported people to access health care services such as chiropody, optical and dental services. One person told us, “They are having my eyes seen to.” A health care professional working regularly with the service told us that staff made timely and appropriate GP referrals and recognised when an urgent referral might be required. One person said, “They noticed my swollen foot and it’s going to get looked at.”

One person said, “The staff are great and anyone would be happy here.” The atmosphere of the service was warm and friendly and there were smiles and laughter between people and staff throughout the day. Relatives and visitors to the service told us they were always made to feel welcome.

People felt listened to and that their opinions mattered. A residents survey was undertaken in February 2016 and there was an action plan in place to address any issues raised. Minutes from regular residents meetings demonstrated that any actions taken as a result of the survey had been effective. Residents were consulted and included in the running of the service and felt that it was their home.

Staff had received training in dignity and respect. They understood how to protect people’s privacy and spoke with them about their care in a respectful manner. Relatives and visitors were made to feel welcome. A visiting health care professional told us how staff were prepared for their visit and always offered them a hot drink. A relative thanked staff at a residents meeting in July, ‘For all the cups of tea they make.’

People received personalised care that was responsive to their needs. People had signed their care plans and individual records contained detailed life histories and lifestyle preferences. For example, one person’s record stated that they preferred to take their meals in their room. Staff knew people well and found ways to support people as individuals. For example, one person was hard of hearing, so staff used a wipe clean board to write down what they were saying if the person was finding it difficult to understand them.

People and staff had confidence in the registered manager who was visible and approachable. The registered manager demonstrated good oversight of the service and understood the needs of people well. They had an inclusive and consultative approach to decision making and actively sought feedback from people, staff and relatives in order to improve the quality of the service.

There was a quality assurance system in place to inform and drive improvements to the service. Infection control and care plan audits had been undertaken and any associated action plans were in progress or completed. Staff were kept up to date with audit outcomes and improvement plans in regular staff meetings.

We identified a breach of the Health and Social care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

Our inspection was undertaken by an adult social care inspector. During this inspection, we looked at the outcomes relating to respecting and involving people, care and welfare of people, the safeguarding of people, staff training and supervision, the process for assessing and monitoring the quality of service.

Below is a summary of what we found. We spoke with five people who use the service, three relatives, the registered nurse in charge, the cook and four care staff. We looked at four care files, staff personal files, four care plans and a number of relevant records.

We used the information to answer the five questions we always ask;

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well-led?

Is the service safe?

We found the service was safe. This was because care plans were comprehensive, reviewed on a regular basis and were up to date. There were individual risk assessments in place that were reviewed frequently and ensured that people who use the service were safe. We found that people's diversity, values and human rights were respected.

We spoke with five people and three visiting relatives. They told us they were well supported. They said that their members of family were treated as individuals and; their dignity and privacy were maintained. They said that staff ensured their safety and they were able to make informed decision about any likely risk.

We found risk assessments in place to ensure that the environment was safe for people who use the service and staff working there. There was a system in place for staff to report any incidents and learn from concerns raised to ensure the safety of people.

We found staff were properly trained and supervised and had the opportunity to improve their skills. This meant that people at the home received care from a team of competent staff.

The Care Quality Commission is required by law to monitor the operation of Deprivation of Liberty Safeguards (DoLS) and to report on what we find. While no applications had been submitted, appropriate policies and procedures were in place. Relevant staff had been trained to understand when an application should be made, and how to submit one.

Is the service effective?

We found the service was effective. This was because people were provided with clear and adequate information about what services were available to them prior to moving into the home. We found where they were able, people expressed their views and were involved in making decisions about their care and treatment.

We observed staff treating people with respect and dignity. For example they would knock on people's door and wait to be asked before entering. They would made sure doors were closed when attending to people's personal needs.

We saw in people's care plans that their capability had been assessed. There was information about the level of support that they required as well as their abilities to lead an independent life. Relatives we spoke with confirmed that their family members were well supported and encouraged to lead an ordinary life as much as possible.

Is the service caring?

We found that the service was caring. We noticed that each person had a personalised care plan that was reviewed on a regular basis. We found that where people's needs had changed, their care plan had been amended accordingly to reflect the changes. This ensured the care and treatment they received were appropriate to their needs.

People we spoke with and their relatives told us the following: 'My wife X has been living here for a number of years and is well looked after', 'X the nurse in charge is very caring and staff are so helpful', 'Dad is well looked after and they understand his needs', 'The home may look a bit tired but cannot fault the care that X my husband had been receiving for the past years'.

We found that people were supported to maintain their dignity and felt free to express their views.

Is the service responsive?

We found that the service was responsive. There was a system in place to deal with concerns and complaints. People we spoke with were aware of the complaints procedure in place. They felt that their views were taken into consideration and acted upon accordingly.

We found that the home offered a range of activities such as arts and crafts, exercises, reminiscence, music and movement, organ playing and celebration of seasonal events. People we spoke with told us they were keen to take part in some of the activities. One person said that I like the exercise routine.

Is the service well-led?

We found that the service was well led. We found that the home had started to carry out resident's survey about the quality of service they offer. We were told that they were in process of sending out questionnaires to people and their relatives.

We looked at responses from the previous survey where only fifty per cent of people who use the service responded. However we found where there had been queries raised within the survey, the home had responded to them appropriately and action taken to ensure that people's views were acted upon accordingly.

Relatives we spoke with told us that they were always asked during their visit if they had any comments or concerns. One person said we just talked to the nurse in charge or X the manager and found that matters were dealt there and then.

Staff we spoke with told us that they had very good support from the management, were able to express their views and felt that they were listened to. We found staff were clear about their role, accountability and worked well as a team supporting each other.

The people we spoke to told us they liked living at the home and that staff were very kind. They told us staff spoke and listened to them in a respectful way, communication was good and that they were well cared for. People told us if they had any concerns or wished to make a complaint they would tell the staff or the manager. One person said 'It's lovely here. They really look after me'.

Visitors we spoke with made us aware they were happy with the care their relatives received. They talked to us about how the staff were 'So kind', that 'Nothing is too much trouble for them' and that the manager was very approachable. They told us that they had involvement in their relatives care. One person said they visited almost every day and were always made very welcome. They told us they had no complaints but knew that prompt action would be taken to address any concerns.