Grasmere 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 the last inspection we rated this key question requires improvement. At this inspection 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.

We found the provider was in breach of the legal regulation relating to good governance.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt by the registered manager and staff, who then used these to identify and embed good practice. Recently, following an incident, the registered manager had worked with staff to improve their understanding of the symptoms and treatment of someone experiencing alcohol withdrawal. Staff told us the review of the incident had led to additional training and they felt it had made a positive difference to their confidence and working practices. However, the provider’s approach to incident management and learning lessons was reactive rather than proactive and issues we found at the last inspection remained.

The registered manager worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. A visiting professional said, “The staff make sure they are extremely well informed about people who may want to move in. They’re adept at supporting people learn skills they need to move on.” A person said, “The staff have been very good and always did stuff in stages.”

The registered manager and staff team worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Staff shared concerns quickly and appropriately. They ensured all safeguarding concerns triggered alerts and followed guidance from the safeguarding team and clinicians about how to reduce reoccurrence of incidents. Staff had training and a good understanding of what to do to make sure people were protected from harm or abuse. The management team ensured Deprivation of Liberty Safeguard (DoLS) authorisations were applied for when needed and any conditions were followed.

Staff worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risk assessments were in place and assisted staff identify how to mitigate risks. We discussed enhancements staff could make around risk assessments related to alcohol and substance misuse, people self-administering medicine and diabetes management to ensure these provided clearer information. For example, one person chose not to follow medical advice when self-administrating their medication and staff needed to record the risks this posed. A person said, “The staff know the score with me and always make sure everything is alright.”

The provider did not detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. An external contractor had produced a fire risk assessment in December 2024, which indicated immediate action was needed to replace fire doors, manage the risk of people smoking in their bedrooms and to check the integrity of each compartment of the home. This document was only shared with the registered manager just before the inspection and no action had been taken to address the concerns, for example around the gaps around doors. Areas of the home needed refurbishment and the flooring in an upstairs shower area continued to let water seep into the ceiling cavity and damage the ceiling below. Despite the length of time these issues had been evident, work only started to address them when we were inspecting the service.

People were supported to be as independent as possible within the environment. The staff team knew who to contact when people might benefit from additional aids or equipment, which staff knew how to use. A person said, “I have the best room in the house and have made it feel homely.”

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. A person said, “There’s always enough staff around and they are happy to help if I need a hand.” Recruitment practices were found to be safe.

The registered manager promoted a learning culture and supported staff to access a wide range of training. The service was designed to provide support for people with mental health needs and staff received mental health awareness, but staff had not received in-depth training around the specific conditions people experienced. Staff also worked with people at various stages of addiction, from denial to recovery. Staff supported people to work through alcohol reduction programmes. Staff received drug misuse and alcoholism awareness training, but no training around motivational assessments, reduction programmes, working with people in denial or the social psychological approach to addition. The registered manager immediately commenced sourcing additional training.

Staff assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Staff appropriately followed the required infection control guidelines.

Staff made sure, where they oversaw them, medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. The staff worked closely with the GP and pharmacist to manage medicines safely and ensure they were received in a timely manner. A person said, “They {staff} know what they are doing; they look after my medicines and make sure I take them at the right time.”