Updated 13 December 2024
Date of Assessment: 19 March to 2 April 2025. Grasmere Lodge is a residential care home providing personal care for up to 20 people with mental health needs and people who experience addictions. At the time of this inspection, 13 people were living at the service.
At the last inspection in April 2022, we identified a breach of regulation in relation to the oversight of the service. We found fire risk management needed to be improved around minimising risks when people smoked in their bedrooms or were reluctant to leave their bedrooms when the fire alarm sounded. We also found improvements were required to the environment around a water leak.
At this inspection, improvements had been made to the provider’s general oversight of the service, but they were reactive rather than proactive when addressing issues. In April 2023, a small fire occurred when a person continued to smoke in their bedroom. Only after this did the provider fully look at actions to minimize the risk of fire. The ceilings had been repaired, and new flooring had been put in place in the shower rooms, but this was now ill-fitting, and water continued to leak into the ceiling cavity and cause damage. The registered manager had identified and repeatedly raised these matters in their audits, and this had fed into the provider’s action plans. However, works were only commenced to address these issues when we started the inspection. These were completed during the inspection.
There were delays in actions required following an external fire audit. The nominated individual confirmed works would commence immediately to address the recommendations contained in the report. Although improvements were being made, the provider remained in breach of the regulation relating to good governance.
Staff understood people's needs and how to manage any presenting risks. Although the assessment template had a section on psychological well-being, it did not assist staff to explore the primary focus of the service; providing support for people with mental health needs and people who experience substances and alcohol dependencies. Improvements were required to risk assessments related to substance misuse, self-administration of medicines and diabetes management.
Staff had received training around the application of the Mental Capacity Act 2005 and associated code of practice. Capacity assessments and ‘best interests’ were in place but these needed further development.
Staff treated people with dignity and kindness. People were supported to enjoy a wide range of activities within and outside the service. Visiting professionals found the staff were caring, compassionate and empathetic to people’s needs. A visiting professional said, “In my opinion, they do amazing work with a group of people who can face a lot of stigma and barriers to day to day living.”
We have asked the provider for an action plan in response to concerns found at this inspection. However, the registered manager worked with the inspection team to make immediate improvements during our inspection.