Grove House Residential Care 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.

The service continues to be in breach of legal regulation in relation to governance of the service.

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.

The provider had a shared vision, strategy and culture. This was based on equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The provider’s values were shared with staff. Staff spoke of an inclusive and supportive working environment where they worked well as a staff team and communicated well with one another. Staff spoke positively of handover meetings. One staff member told us, “Handover is good. We have them at the start of each shift with the senior or the deputy. They tell us everything we need to know, and they write it all down. So, you can always go back and check if you’re not sure about anything.”

Staff told us they had regular meetings with management staff to discuss issues relating to their work practice and the home. One staff member told us, “We discuss how to care for residents, any complaints from relatives. We can give our views. We can discuss with the manager about things that need to be done.” They told us when suggestions were made, they felt the registered manager listened to them which meant they felt at ease to raise any issues needing addressing with them.

Staff felt supported in their roles and told us about improvements made to the service since the last inspection. Managers had increased observations of staff so they could provide clear leadership and model good practice indicating a supportive culture in the home. Staff and managers spoke positively about the care being provided to people.

The provider had leaders at all levels who understood the context in which they delivered care, treatment and support to create a positive culture within the home. Changes in management practice were still being embedded to demonstrate high standards of care were consistently maintained.

The registered manager was committed to the delivery of compassionate care and told us how they ensured staff were supported when needed on the floor. We saw how management staff and care staff worked together to ensure people’s needs were met. However, we found there continued to be areas of improvement needed within the service, some of which had not been identified from audit checks completed. Quality assurance processes were still being embedded into the service.

Staff told us managers were visible and gave them support and guidance. Staff were positive about managers and said they demonstrated a caring attitude towards them. One staff member told us, “Things have really improved and keep improving. We are working hard. We talk about everything, and we can say what you think.” Another staff member told us, “I like working here, this is my second home, I know people and love talking to them, I understand how they feel as I know I will be like them one day.”

The provider fostered a positive culture where people felt they could speak up, and their voice would be heard.

Staff told us they felt listened to as managers responded to issues they raised. Staff had received training in safeguarding and understood their responsibility to speak up on behalf of people if needed. Staff were given opportunities through daily handover meetings to raise any concerns or issues they needed to share.

Staff were aware of the provider’s whistleblowing policy which gave them information of who they could contact if they felt their concerns were not being taken seriously or were not resolved by the management team. One staff member told us, “If you find something is not right you have the right to report it to the manager. If they don’t address it, go to the owner and if they didn’t do anything CQC.”

People were positive about the staff and told us if they had any concerns they would speak with the staff or the manager. Relatives told us they had regular contact with the home and felt at ease to raise any issues with management if needed. One relative told us, “They get relatives’ views through relatives’ meetings. They had one 2 to 3 weeks ago and I have seen notices for them”. This person went on to say, “As a family we are more than happy with the service. I have never had any issues but if I did, I would talk to [registered manager] knowing it would be dealt with and not ignored.”

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 spoke of an inclusive environment where equality and diversity were promoted. Staff told us they felt included in decisions about the service and spoke positively of the provider. The registered manager and deputy manager worked closely with staff to ensure there was no bias in everyday practice and to ensure they worked in accordance with the provider’s policies and procedures.

One staff member told us how management were supportive of them in terms of working flexibly in relation to their working patterns to support their personal needs.

The provider’s policies and procedures supported staff in their understanding of equality and diversity.

The provider had clear responsibilities, roles, systems of accountability and governance systems but these were not consistently effective. The provider did not always act on the best information about risk, performance and outcomes, to deliver consistent good quality, sustainable care, treatment and support.

The registered manager told us how since the last inspection the provider had arranged support in making the required improvements to the service. This included the support of an external provider who completed quality monitoring and audit processes. Since the last inspection, action had been taken to ensure checks completed by the manager and provider were recorded.

Whilst we identified significant improvement of the service, there continued to be shortfalls with the provider’s quality assurance system. Issues we had identified had not been picked up in the provider’s quality audits. For example, the registered manager conducted a daily 'walk around' of the service which they explained was used to observe staff practice and to check the environment. These had not identified concerns including exposed hot water pipes, unprotected radiators, and pedal bins that did not work. Care plan reviews and checks had not clearly identified there were no care plans for some people’s health conditions to help staff understand how to manage them. The deputy manager explained they were aware of the missing care plans for a new person and had been working to obtain additional information to enable them to be completed.

People were generally positive about the service but gave mixed responses in regards to being asked about their views and actions being completed. One person said, “If I was not happy about anything, I would talk to any of them. They are easy to talk to but don’t always do what you ask them.” Another said, “There is no formal feedback as such sought from me, they just ask if you want anything and get it for you. They are very good in that sense.”

The registered manager told us people’s views were sought during resident meetings, and this was confirmed in notes of the meetings we saw. However, it was not always clear what action had been taken in response to issues raised to show people’s views were taken seriously. The registered manager told us this would be addressed.

Following our last inspection in August 2024, we expected improvements would have been made to fully comply with all regulations. However, we found repeated breaches of the same two regulations and the rating of the service remains requires improvement in safe and well-led. Action is needed to ensure improvements are sustained.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people, but this was not always fully effective. They shared information and learning with partners and collaborated for improvement.

People had access to some activities in the home and within the community. The registered manager told us “keep fit” took place in the home twice weekly by an external provider which people enjoyed. Records were not consistently maintained to show community activities people wished to attend or attended. The registered manager agreed they would ensure this was recorded so this could be more effectively monitored.

Staff spoke positively of relationships with healthcare professionals to support people’s needs. They also recognised the importance of keeping relatives informed about their family member. Commissioners confirmed the provider regularly engaged with them to support improvements in the home.

Records demonstrated people had been referred to other healthcare professionals when required, including dieticians, the GP and district nurse.

The provider focused on continuous learning, innovation and improvement across the organisation and local system, but this was not continually sustained. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people.

The registered manager told us how learning had been taken from the last inspection and described improvements made. For example, there had been improvements to medicine management with regular checks to ensure this was managed well. There had been changes to the environment with actions progressed in regards to the legionella and fire risk assessments. We saw quality assurance systems had been further developed with more audits and systems in place to ensure the service was safe. Some of these audits had been effective whereas others had not in regards to identifying issues needing action. For example, some care plans were not in place for people’s specific health conditions. This meant care may not always be managed safely and consistently. The registered manager took action following our visit to address this.

Staff told us their views on improving the service were listened to with 1 staff member explaining, “The manager is available to staff and if anyone has anything to say, they can. We talk about things and any changes we need to make and how we can improve.”