Grasmere Nursing Home

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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

At this inspection we found the provider to be in breach of regulation, in respect of Governance. There was a failure to act on information of concern in a timely manner or report concerns to relevant agencies. On going failures to follow the MCA appropriately and failure to have in place robust quality assurance systems above manager level.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People were supported by staff who had shared values and promoted transparency and learning.

People, staff, and relatives commented on the positive attitude of managers and staff. One staff member said of leaders, “We have always had good managers and the owner is approachable.” A relative told us, “They [managers and staff] are open about what they are doing, the nurses are good and manage well.”

Systems and processes including meetings and staff supervisions promoted a listening culture and equality, and diversity were recognised and supported.

High-quality leadership was not always sustained through safe, effective and inclusive recruitment planning.” For example, there was a failure to appropriately disclose required employment information in a timely and transparent manner. This was discussed with the provider following the inspection visit who then took action to address the concerns.

The provider had a proactive and positive culture of safety in respect of incidents and accidents. Staff listened to concerns about safety, investigated and reported safety events. Lessons were learnt to continually identify good practice. Records of incidents and accidents were made, and these were audited monthly and included a lesson learnt section. Staff told us they had regular meetings where they discussed incidents and how to reduce future re-occurrence. For example, one person was very subdued and seemed unhappy, staff suggested they be offered a different room as they felt this might be part of the concern. The person was offered a different room with more light and a better view. they moved as soon as they could and has remarked how much happier they are.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff said they enjoyed working at Grasmere. Staff said they had felt welcomed into the service and were given enough information and training to enable them to undertake their roles. One staff member told us, “You can come with ideas and always listened too, for example we suggested we move a bed so the person could get more light, that was discussed and done.” Another said, “It’s a good team, we all get on well together, always happy to come to work.”

The duty roster showed staff working various hours indicating flexible working.

Records showed staff received regular face to face supervisions and staff confirmed this. Supervisions provided an opportunity for staff to discuss any concerns or thoughts related to career progression. Staff told us they valued the time they had to have staff meetings and one to one supervision. Staff came from diverse backgrounds, and they told us their different cultural needs were respected.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. The provider had failed to act effectively upon information of concern raised with them 7 months earlier. They had failed to ensure appropriate information was gathered or shared with the relevant agencies in order to safeguarding people. The provider did start to take steps to gather and report information, a risk assessment was updated and a business contingency plan to cover the particular circumstances put in place. However, whilst some mitigation had taken place the situation was not fully resolved.

At the last inspection there continued to be a breach of legal requirements regarding the governance of Mental capacity act (MCA) assessments. The providers quality assurance system had failed to identify that assessments were generic and not completed to ensure specific decisions were assessed. The provider failed to assure themselves leaders had the necessary knowledge to carry out MCA and best interest decisions in line with guidance. The provider did not have a system in place to monitor or review possible restrictive or intrusive practices. Whilst we found no evidence of direct harm this had the potential to deny people of their human rights. This was raised by the inspector and new forms containing the decision to be assessed were produced, however these were still not completed in line with guidance and did not contain adequate detail to demonstrate a full assessment had been carried out. In addition, at the time of the visit the provider had failed to identify the lack of consent agreements to the use of CCTV and the lack of identifying signage to alert visitors to the presence of CCTV.

The providers quality assurance systems had failed to identify shortfalls in medicines management. We reviewed medicine audits carried out by the manager 01 May 2025 which identified discrepancies in stock control of medicines. These were still present at the inspection visit on 24 June 2025. Sufficient action had not been taken to address the issue and reduce the potential risk to people. The area manager confirmed the system to audit the service was for the manager to carry out internal audits and send a report to the provider. The provider did not have direct and clear audit systems in place to be assured of compliance as in effect the manager is auditing their own work without robust assurance audits taking place to confirm accuracy and compliance.

The provider has a condition on their registration which states “The registration of the provider of this regulated activity is subject to a registered manager condition under Regulation 5 Care Quality Commission (Registration) Regulations 2009.” The provider has not registered a manager since June 2022. The current manager has been in post since the summer of 2024 and has not yet applied to register with CQC.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. One health professional told us, “The team at Grasmere are always friendly and welcoming. The team tend to call and ask for advice on nursing issues such as catheters, or appropriate equipment, just as an example. I believe they have a robust training programme for staff and strong leadership.”

Relatives also told us that their loved ones had appropriate referrals made to other health and social care professionals when required.

People received ongoing support from various external health and social care professionals who represented them. Staff and leaders understood their responsibilities to work in partnerships with external care professionals to ensure people received joined up care.

There was evidence in the care plans and daily notes the provider had liaised with various health professionals to ensure safe care and treatment for people living in the service.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. The provider had failed to take action on some areas of concerns from the last inspection. A robust auditing system and service development plans were not in place There were some audits carried out at the service which, although they had mixed outcomes, did identify issues resulting from accidents and incidents and lessons were learnt and changes made. For example, exploring people’s health needs for potential changes after a fall.