Grasmere Lodge

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 leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At the last inspection we rated this key question requires improvement. At this inspection the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care. 

The provider was previously in breach of the legal regulation in relation togood governance. Improvements were found at thisassessmentand the provider was no longer in breach of this regulation.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The management team had a shared vision, strategy and culture which promoted person-centred care and positive outcomes for people. Staff consistently described a caring and supportive culture and told us they felt listened to, valued and involved in the development of the service. Staff spoke positively about the registered manager and management team and said their views and opinions mattered. They told us there were regular staff meetings where information was shared, improvements discussed and suggestions acted upon.

Feedback from relatives and professionals demonstrated the culture of the service was focused on supporting people to achieve meaningful outcomes. External professionals described staff as person-centred, compassionate and committed to helping people regain confidence, improve independence and access opportunities within their communities. A staff member said, “All we want is for people to get the best out of their life.”

The registered manager was visible, approachable and demonstrated a commitment to providing compassionate and inclusive care. Staff consistently told us they felt supported by the registered manager and the team and were confident they could approach them for advice, guidance or support. They said concerns were taken seriously and acted upon promptly. Regular supervision and staff meetings provided opportunities for support, development and discussion. Professionals spoke positively about the management team within the service. They described the registered manager as approachable, responsive and flexible.

Professionals found the registered manager had developed strong relationships with people living at the service and maintained a visible presence, enabling them to understand people's needs and promote positive outcomes. Relatives were highly complimentary about the registered manager and staff team and described the leadership of the service as a significant strength. A visiting professional said, “I have been particularly impressed by Grasmere Lodge's person-centred ethos, proactive support, inclusive values, and commitment to helping residents achieve meaningful outcomes. The positive changes I have already observed in this client's wellbeing and confidence are a testament to the dedication and quality of care provided by the staff team.”

The registered manager promoted a culture where people and staff were encouraged to speak openly and share their views. Staff told us they felt able to raise concerns and were confident management would listen and respond appropriately. They described leaders as supportive and said concerns they had raised had been dealt with quickly and effectively. Staff also told us they were encouraged to contribute ideas and suggestions through meetings and discussions about service improvement. A staff member said, “If I have had to raise any concerns, I feel these have been taken seriously and dealt with quickly. We have regular staff meetings which I think is very useful so I can share any information and we can talk about any improvements that are needed within the workplace.”

The provider promoted equality, diversity and inclusion across the workforce and supported staff to feel valued, respected and included. Staff completed training in equality, diversity, human rights and person-centred care and these subjects were regularly discussed through supervision and team meetings. Staff described feeling valued and listened to by managers and said they were supported to undertake training, development and progression opportunities.

The provider had continued to improve the governance arrangements since the last inspection. They had introduced revised governance arrangements, key performance indicators, audit processes and management reviews intended to strengthen oversight and accountability. They had addressed several concerns identified at the previous inspection, including fire safety issues, maintenance concerns and environmental risks.

Audits and quality assurance processes were being used to monitor the service and identify improvements. However, at times, governance arrangements were not always sufficiently proactive. There had been some delays in completing electrical remedial works following a periodic inspection. Although some delays were attributable to external contractors, the provider's review identified additional internal approval processes needed to be improved and acknowledged monitoring and escalation arrangements required strengthening. The provider subsequently introduced clearer timescales, escalation processes and monitoring arrangements for remedial works.

In addition, the provider continued to rely on handwritten documentation, which they acknowledged could impact the timely updating, review and sharing of information. While leaders recognised these issues and had plans to improve systems, governance processes were not always fully effective in identifying and addressing concerns at the earliest opportunity.

Staff worked well in partnership with other organisations and community services to promote positive outcomes for people. Professionals consistently described collaborative working relationships and told us staff communicated effectively and involved them appropriately in people's care and support. A professional said, “I have always found Grasmere Lodge to be a very caring, effective, establishment. The staff work in a safe and responsive way to meet their clientele's needs, and I have always found it to be well led.”

The provider now had systems which supported learning and improvement across the service. Accidents, incidents and safeguarding concerns were reviewed and analysed to identify lessons learned and opportunities for improvement. Staff told us learning was regularly shared through meetings and discussions, and they were involved in conversations about improving the service. The provider demonstrated a willingness to reflect on shortcomings and make improvements. Following previous concerns, the provider had introduced revised governance arrangements and had undertaken reviews of maintenance and compliance processes. Learning from identified issues had resulted in strengthened monitoring, escalation arrangements and clearer oversight of remedial actions.