Grovelands Lodge

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

At our last assessment, the provider was in breach of the legal regulation safe care and treatment. At this assessment, the service remained in breach of legal regulation in relation to safe care and treatment. The provider was also found to be in breach of legal regulation in relation to fit and proper persons employed.

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.

Accidents and incidents were recorded, with details of what had happened, and the provider had an accident and incidents folder. However, there was no overall analysis of accidents and incidents, which meant the service was not able to monitor themes and trends.

The management and oversight of safety at the service was not always adequate. Systems were not always in place to identify and act on all safety concerns.

Staff told us they felt they could approach management if they had any concerns. One staff member told us, “Management have created a supportive environment where concerns are taken seriously and addressed promptly. Another staff member told us, “It’s reassuring to know that feedback is welcomed and acted on.

Staff meeting minutes showed learning from accidents and incidents was shared across the team.

The provider had systems and processes in place for pre assessment prior to admission to Grovelands Lodge and worked with external stakeholders such as health providers. The provider made sure there was continuity of care when people moved between services. For example, systems were established to ensure people were supported by staff if they needed to go to hospital.

The provider had safeguarding processes in place with policies and procedures to protect people from abuse; however, these were not always robust, and we found some inconsistencies and gaps in people’s care plans and risk assessments which meant risks to people’s safety could be compromised. For example, there had not always been appropriate oversight from management to ensure that people were always kept safe.

Staff had received training in how to safeguard people from abuse and understood how to report concerns. Staff told us they felt confident with reporting any concerns. Comments included, “Management are approachable and take concerns seriously” and “If I have a concern, I feel comfortable speaking up.” We saw evidence of safeguarding being discussed in staff meeting minutes.

People and their relatives told us they felt safe here. One relative told us, “I have no issues with [relatives’] safety.”

We observed people appeared to be comfortable living at Grovelands Lodge. We observed positive interaction between staff and people.

People’s care plans and risk assessments did not consistently contain sufficient information to guide staff about the required actions to mitigate potential risks and were not always reviewed and updated. For example, one person’s care plan did not consistently detail their needs around their diabetes and how to manage this.

Personal Emergency Evacuation Plans (PEEPS) had been completed; however, they contained minimal information and had not been regularly reviewed. PEEPS give staff or the emergency services detailed instructions about the level of support a person would require in an emergency such as a fire evacuation.

During our assessment we did not see clear involvement of people in their care plan and risk assessment reviews. However, the provider has since provided evidence that people were being involved in their care planning and risk management.

The provider did not have effective processes in place to monitor equipment and facilities. They did not detect and control potential risks in the care environment. For example, improvements were needed in relation to individual personal emergency evacuation plans (PEEPS) which would be used in the event of an emergency such as a fire. The information was minimal and had not been reviewed regularly.

We found that not all fire safety checks were being maintained. For example, the fire risk assessment was out of date and there was no evidence of regular fire drills being completed. The provider has since reviewed and updated the fire risk assessment, completed an environmental check and completed a fire drill. This identified the need for a more effective fire safety logbook and the provider now has an allocated fire marshall.

The provider had recruitment processes in place. We found some gaps in documentation in a staff members employment history, application forms and references. This meant the provider was not enabled to explore gaps in employment and consistently apply for professional references. We addressed this with the registered manager who was able to provide us with the appropriate documentation.

We reviewed training records and found there were some gaps for staff and some training that was showing as out of date. This was raised with the registered manager who acted quickly to ensure all staff were up to date. Staff told us they felt supported with learning new systems and gaining feedback. One staff member told us, “I have had additional support to use the computer as we document a lot of information electronically to save paper. I receive regular feedback on how I can improve which I appreciate.”

People and their relatives told us they felt safe, and staff were kind and caring. One family member told us, “The staff here are very welcoming and approachable.” Staff feedback did not identify any concerns with the staffing levels and staff felt confident in supporting people at Grovelands Lodge. Comments included, “We have the right training and skills to provide a high standard of care, and it shows in the way we handle both day-to-day needs and more complex issues.”

We observed enough care staff supporting people at Grovelands Lodge. Staff knew the people well and we observed people and staff were comfortable in each other’s company.

The provider did not always have effective processes in place to monitor infection prevention and control. There were audits in place for cleaning schedules, and we did not identify any gaps in these. However, the audits had not identified issues such as a build-up of mould on the shower curtain in the communal bathroom and floor defects in the kitchen. We did not see evidence of the monthly environmental check being completed every month.

During our assessment, we found some of the communal floors were stained and worn and in need of repair or replacement. The provider has since confirmed that a new shower curtain has been purchased, and the carpets have been professionally cleaned. A relative told us, “The place does look a bit worn, I have fed this back to management.”

People received their medication from trained staff. Records showed that staff were up to date with their medication training. The provider had a medication policy in place and ongoing assessment of competencies for staff.

We reviewed medication administration records (MAR) and found no concerns. There was information available on how people took their medicines. When reviewing ‘as required’ medication protocols, we found that they required more detail to minimise potential errors and ensure administered correctly to reduce any risk or potential harm to people. This was fed back to the registered manager during the assessment.

The provider had medication audits in place, for example, a weekly medicines audit for boxed medication. However, we did identify that with the daily medication audit it was not clear what was being audited, however this was being carried out daily.