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Inspection carried out on 25 August 2020

During an inspection looking at part of the service

Grasmere Rest Home is a 'care home' for older people, some of whom live with dementia. The service can accommodate up to 25 people. There were 22 people living at the service at the time of this visit.

We found the following examples of good practice.

• The service booked visits for families and friends and staggered the times of visits to reduce the risk of infection transmission between people. Visits took place in the garden or in a designated area in the lounge. Visitors had their temperature taken before entering the home, were screened for Covid 19 symptoms and provided their contact details for test and trace purposes. Visitors were given Personal Protective Equipment (PPE), including hand sanitiser and face masks, which they had to wear throughout their visit. The service provided detailed guidance to staff and visitors on how to put on and take off PPE.

• Staff were allocated to work in specific areas of the home, with specific colleagues to reduce the risk of spreading infection. People that were isolating or shielding had their own dedicated staff who provided a support bubble to support all their needs. The home used video calls to make sure people had regular contact with their families and friends and to provide people with activities.

• The service had an infection prevention and control lead and people were admitted into the home in accordance with national guidance. The provider made sure people being discharged from hospital had been tested before being admitted into the home. The provider was regularly testing people and staff for Covid 19, in accordance with government guidance.

• The provider supported people and staff to stay safe. Staff had been trained and were confident in the management and prevention of infection. Additional measures had been introduced to clean the service and make sure the risk to people and staff was reduced. Staff had individual Covid 19 risk assessments. Examples included, the risk of staff using public transport to get to work and staff in higher risk categories, including Black, Asian and Minority Ethnic staff. The provider’s infection prevention and control policy and business contingency plan had been updated to include Covid 19.

Further information is in the detailed findings below.

Inspection carried out on 21 May 2019

During a routine inspection

About the service: Grasmere Rest Home is a residential care home that was providing personal care to 19 people at the time of the inspection.

People’s experience of using this service:

People received care from staff who were exceptionally friendly, compassionate and caring. There was a strong person-centred culture that showed people were valued and respected. Because staffing was consistent, people and staff had opportunities to get to know one another well. Staff promoted inclusivity and encouraged people to form friendships. People felt comfortable and well supported as a result.

People received the support they needed to make choices about the care they received. This included accessible information about upcoming events. Staff promoted people’s privacy, dignity and independence.

The provider had made improvements to the safety of the service since our last inspection in October 2016. There were regular checks to make sure the environment and equipment people used were safe. The premises were suitably adapted to meet people’s needs. People had individual, personalised risk assessments and risk management plans so staff knew how to care for them safely. This gave people the freedom to take positive risks such as going out by themselves. Staff knew how to safeguard people from the risk of abuse. The provider took appropriate action in response to accidents and incidents, to reduce the risk of them happening again.

There were enough suitable staff to care for people safely. Staff received support and training to carry out their roles effectively. They followed best practice guidance to protect people from the risk of infection and knew how to manage medicines appropriately and in line with best practice.

People received enough nutritious food and drinks. People were able to access healthcare services when they needed to. The provider worked well with other services to make sure people’s healthcare needs were met.

The provider assessed people’s needs and planned care in line with best practice, consulting other agencies for information and advice when appropriate. The provider used information from assessments to plan person-centred care, involving people and their relatives in the process. People received compassionate care and support at the end of their lives.

Staff obtained people’s consent before providing care, or, where people did not have the capacity to consent, followed processes to ensure decisions made about people’s care were in their best interests and in line with legal requirements.

Staff supported people to choose and participate in various activities that kept them physically and mentally active and took their abilities and interests into account.

People knew how to complain if they needed to. The provider responded promptly to people’s complaints and used them to improve the service. They also used feedback from people, their relatives and stakeholders on a regular basis to help them make improvements. There were opportunities for people, relatives and staff to be involved in the running of the service. Leadership at the service was visible and well organised and staff worked well as a team. The registered manager was open and approachable.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection: At the last inspection, this service was rated Good (published 17 November 2016)

Why we inspected: This inspection was part of our scheduled plan of visiting services to check the safety and quality of care people received.

Follow up: We will continue to monitor the service to ensure that people receive safe, compassionate, high quality care. Further inspections will be planned for future dates.

Inspection carried out on 6 October 2016

During a routine inspection

This inspection took place on 6 October 2016 and was unannounced. At our last comprehensive inspection in July 2015 we found the service was in breach of regulations relating to safe care and treatment and good governance and rated it as requires improvement. This was because medicines were not managed safely, risks such as those relating to falls and people developing pressure ulcers were not managed safely and audits were not sufficiently robust. However, when we carried out a follow up inspection to check these areas in December 2015 we found the provider had taken appropriate action and the service was no longer in breach of the regulations. We did not change the rating of the service at that inspection because we wanted to see sustained improvements over time.

Grasmere Rest Home provides accommodation and personal care for up to 23 people, some of whom may be living with dementia. At the time of our visit, there were 20 people using the service. Although the service is required to have a registered manager in post, there was no registered manager at the time of our inspection because this person had recently left the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We found some risks were not managed safely. Cleaning and laundry chemicals were kept where people could access them and potentially come to harm from contact with them. There were insufficient measures in place to manage risks relating to people’s cigarette lighters where they did not have the mental capacity to operate and manage these safely. However, the provider promptly installed a lock on the cupboard where chemicals were kept and the acting manager told us they would review policies around use of smoking materials.

People had personalised risk assessments and these were up to date. Staff knew how to protect people from risks like falls and developing pressure ulcers and there was sufficient equipment in place to manage these risks. Measures were in place to protect people in the event of emergencies and the provider had taken action to help ensure people were protected from the risk of harm and abuse. Medicines were managed safely. Staff were familiar with medicines policies and arrangements were in place to store, administer and record medicines appropriately.

There were enough staff to care for people safely and so that people did not have to wait a long time for help. The provider carried out checks to ensure they did not employ any staff known to be unsuitable. Staff received the training and support they needed to do their jobs. They were able to obtain advice from healthcare professionals about supporting people’s health needs. People had access to healthcare services when needed and were able to choose from a variety of nutritious food and drinks that met their needs.

Staff obtained people’s consent before carrying out care tasks. Where people were unable to consent to their care, staff followed procedures to make sure they worked within the Mental Capacity Act (2005). This included situations where people were deprived of their liberty within the care setting and ensured that the provider was meeting legal requirements in this area.

Staff were caring and showed respect, empathy and compassion in their interactions with people. They regularly checked that people were comfortable and whether they needed anything. They knew people well and took time to listen to them and talk about their experiences. Staff worked with people in a way that promoted their dignity.

People were free to choose how to spend their time and took the lead on deciding what their daily routines should be. People enjoyed trips and outings including a recent canal boat trip and

Inspection carried out on 19/01/16

During an inspection looking at part of the service

This inspection took place on 19 January 2016 and was unannounced. At our last focused inspection on 19 October 2015 we found the provider was not meeting legal requirements in relation to safe care and treatment and good governance. We served the provider a warning notice in relation to the breach of regulation in relation to good governance and served a requirement notice for the breach of regulation related to the safe care and treatment of people. After the inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches.

We undertook this focused inspection to check the provider had followed their action plan and to confirm that they now met legal requirements and had addressed the areas where improvements were required. We found the provider had taken all the necessary action to improve which meant they were no longer in breach of regulations.

This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Grasmere Rest Home on our website at www.cqc.org.uk

Grasmere provides accommodation for up to 25 older people some of whom were living with dementia. During our inspection there were 19 people using the service.

There was no registered manager in post although the manager who had started in March 2015 was in the process of registering with CQC. A registered manager is a person who has registered with CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The provider had made improvements to medicines management systems which meant they had taken action to protect people against the risks associated with medicines. Our stock checks indicated people received medicines as prescribed and that records the provider made regarding medicines were accurate. The provider had introduced effective medicines audits so they regularly checked that people received their medicines as prescribed.

The provider had reviewed the tool they used to assess people’s risk of developing pressure ulcers. However the provider did not always assess people’s risk of developing pressure ulcers monthly when required. This meant they may not be using the tool appropriately to check people received the right support. The provider put in place the right support people needed when they identified they were at risk of developing pressure ulcers.

People received the right support in relation to falls. The provider referred people promptly to the falls prevention team, a specialist NHS service, and followed the advice provided.

The provider carried out a range of audits including regular checks of care plans and risk assessments, records maintained about falls and training, DoLS authorisations, medicines and other aspects of the service. The director told us they would create a deputy manager role to support the manager to oversee the service and review care records as necessary. Appropriate health and safety checks were in place and the provider was on schedule with regards to their action plan to reduce the risks of Legionella in accordance with their Legionella risk assessment. These audits were effective in identifying and rectifying issues as part of improving the quality of service provided to people.

Inspection carried out on 19/10/2015

During an inspection looking at part of the service

This inspection took place on 19 October 2015 and was unannounced. At our last comprehensive inspection on 2 and 13 July 2015 we found the provider was not meeting legal requirements in relation to safe care and treatment and good governance. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches.

We undertook this focused inspection to check the provider had followed their action plan and to confirm that they now met legal requirements and had addressed the areas where improvement was required. We found the provider had not taken all the necessary action to improve the service in respect of the breaches we found which meant they were still in breach of regulations.

This report only covers our findings in relation to those requirements and some other areas where the provider told us they would make improvements, such as supporting people in relation to their risk of falling and risk of developing pressure ulcers. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Grasmere Rest Home on our website at www.cqc.org.uk.

Grasmere provides accommodation for up to 25 older people some of whom had dementia. During our inspection there were 22 people using the service.

There was no registered manager in post although the new manager who had started in March 2015 had started the process to register with CQC. A registered manager is a person who has registered with CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Although the provider had made some improvements to medicines management systems, we found that the provider was not adequately the risks associated with medicines. Our stock checks indicated people may not always have received medicines as prescribed. Accurate records of medicines received and carried over into a new cycle were not always made which meant the service could not always be sure of their stock balances. Daily checks of medicines administration and monthly audits of medicines systems were in place, but these were ineffective as they had not identified the issues we found.

The provider had installed air conditioning in the medicines storage room with daily temperature monitoring which meant medicines were stored at a safe temperature. Protocols to guide staff as to when to administer as required medicines were mostly in place for staff to follow in administering these medicines safely, the manager was in the process of completing the last protocol. The manager had introduced a competency assessment to check staff administered medicines safely.

The provider did not always assess people’s risk of developing pressure ulcers accurately as they were not using an assessment tool properly. This meant people may not be receiving the right support in relation to their actual risk of developing pressure ulcers.

The provider had updated their falls policy to incorporate best practice guidelines on identifying why people were experiencing falls and address environmental hazards more clearly. Records relating to people’s falls were clearly made and most people received the right support in relation to falls. However, one person may not have received the right support in relation to falls as advice from the falls team who had supported them was not recorded in their management plans, or information about their observed behaviour in relation to falls.

A range of health and safety checks were in place and the provider had recently had a Legionella risk assessment carried out which identified several high risks in the home. The manager confirmed an action plan was in place to address these issues to reduce the risks to people. Regular checks of the environment were in place including checking window restrictors remained suitable so people were at reduced risk of falling from height.

The provider had introduced a monthly manager’s audit since our last inspection. The manager checked various aspects of the home and reported concerns to the provider. However, records of a number of these audits could not be located by the manager. In addition, we saw that this audit was not comprehensive and had not identified the issues we found.

At this inspection we found a breach of regulation in relation to safe care and treatment. You can see the action we told the provider to take at the back of the full version of this report. We also identified a breach of regulation in relation to good governance. We served a warning notice in relation to this breach for the provider to be compliant by 28 December 2015.

Inspection carried out on 02/07/15 & 13/07/15

During a routine inspection

This inspection took place on 2 and 13 July 2015 and while the first day was unannounced we arranged the second day with the provider to ensure they would be there to provide the information we required. At our last inspection on 26 February 2015 to follow-up on two breaches we found the provider was meeting legal requirements in relation to consent but not in relation to care and welfare of people. We found that some risks identified by incidents or assessments had not been assessed and were not being adequately managed as a result. We served the provider a warning notice and at this inspection we checked whether the provider had taken sufficient action to meet the breach. We also carried out a comprehensive inspection.

Grasmere provides accommodation for up to 25 older people some of whom had dementia. During our inspection there were 22 people using the service.

There was no registered manager in post although the new manager who had started in March 2015 told us they had started the application process to register with CQC. Our records showed we had not yet received their application at the time of the inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Medicines management was not always safe. The provider had not acted promptly to ensure medicines were stored at a suitable temperature which would not damage them, despite being aware of this issue before our inspection. However, the provider took appropriate action once we raised our concerns. We could not always confirm people had received their prescribed medicines as staff had not appropriately maintained medicines records. Guidance was not always in place for ‘as required’ medicines. This meant staff may not have known the signs to look out for which meant people needed these medicines, particularly when people were unable to tell staff they needed them.

Systems were in place to assess and monitor the quality of service although audits were not always recorded and had not always identified the issues we found.

In general the service managed risks to people well and the service had made improvements in response to concerns we identified at our previous inspection. In addition, the service was updating their falls policy to incorporate best practice guidelines on identifying why people were experiencing falls and to identify and address environmental hazards more clearly. The manager analysed accidents and incidents to look for patterns and to check people received the right support.

A range of checks were in place to ensure the premises and equipment were safe and the home was well maintained. However, the checks had not identified several window restrictors could be overridden and people may have been at risk of falling from height. The provider immediately installed appropriate restrictors during our inspection when we raised our concerns with them to keep people safe.

Staff monitored people’s risk of malnutrition and sought advice from dietitians and speech and language therapists when they were concerned about people. Staff provided people with a choice of food and drink and supported them to eat and drink where necessary. Staff supported people to access health services such as GP, dentist, optician and chiropodist and more specialist services such as the district nurse for pressure area care, the falls prevention team and the challenging behaviour team.

Systems were in place to safeguard people form abuse. Staff were aware of the signs people may be being abused and how to report this as they received training on this. When allegations of abuse had been made the provider took prompt action to keep people safe, carried out an investigation and liaised with the local authority safeguarding team as required.

Recruitment was safe because the provider carried the required checks before staff worked with people to see whether they were suitable. This included checking references, criminal records, qualifications and training, photographic identification and health conditions which could mean they were unable to carry out their role without reasonable adjustments being made.

A system of staff supervision and appraisal was in place and staff told us they felt well supported by the manager and provider. Staff received appropriate induction when starting their roles and a programme of training was in place to equip staff with the knowledge they required to meet people’s needs.

Staff understood their responsibilities under the Mental Capacity Act 2005 and received training in this and the service was meeting their requirements under the Deprivation of Liberty Safeguards (DoLS). These safeguards are there to help make sure that people in care homes and hospitals are looked after in a way that does not inappropriately restrict their freedom. The provider had assessed whether people required DoLS and made the necessary applications as part of keeping them safe.

People and their relatives told us staff treated them with kindness, dignity and respect and our observations were in line with this. Staff knew the people they were supporting well, including how they liked to receive their care and this information was available for reference in people’s care plans. End of life care plans were in place for people so staff knew how they preferred to receive their care during their final days.

A programme of activities was in place led by an activities officer, and people were supported to do activities they were interested in.

A complaints system was in place and made accessible to people and their relatives. The manager and provider responded to concerns people raised appropriately.

We identified two breaches of the Health and Social Care (Regulated Activities) Regulations 2014 during our inspection. You can see what action we told the provider to take at the back of the full version of the report.

Inspection carried out on 26 February 2015

During an inspection looking at part of the service

At our previous inspection in April 2014, we found that people's consent to their care was not always sought before they received care, that legal requirements were not always adhered to where people did not have the capacity to consent and that care was not always planned and delivered in a personalised way. Risks were not adequately assessed and managed and there was not sufficient information about people's end of life wishes to ensure that these were carried out.

At this inspection, we spoke with three people who used the service, two care workers, a representative of the provider organisation and the registered manager of a sister service, who told us they were assisting with the management of Grasmere Rest Home while recruitment of a new manager was taking place. We looked at three people's care plans. We considered our

inspection findings to answer the questions we had asked previously: Is the service safe? Is the service effective? Is the service responsive?

Was the service safe?

Some aspects of the service were not safe. Some risks identified by incidents or assessments had not been assessed and were not being adequately managed as a result.

Was the service effective?

The service was effective. People told us they were asked for their consent before care tasks were completed. They said, "They involve us and discuss our care. We work it out together over a cup of tea.� Another person said, �The manager asked me about my care and got my consent.� Staff were knowledgeable about the Mental Capacity Act and there was evidence that this had been applied appropriately when there were doubts over whether people had the capacity to consent to decisions about their care. People received support from healthcare professionals when they needed it.

Was the service responsive?

The service was not consistently responsive. People had personalised care plans, including information about their end of life wishes. However, the care plans were not always updated to reflect people's changing needs. People told us they received care and support in accordance with their needs and wishes. One person said, "I love it here. [Staff] take care of me. There's always someone here for me when I need them."

Inspection carried out on 11 April 2014

During a routine inspection

When we visited Grasmere Rest Home, there were 18 people using the service. We spoke with three people who used the service and four members of staff. We reviewed five people's care plans and five staff files.

A single inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

Is the service safe?

The premises were safe and well maintained. Staff had training in dealing with emergencies and were aware of how to manage them. Good recruitment procedures were in place to reduce the risks of inappropriate staffing. People's risks were not always individually assessed and some had no management plans in place. In some cases, this meant that there was no formal framework in place to ensure that people were protected against the risks of unsafe or inappropriate care. A compliance action has been set for this and the provider must tell us how they plan to improve.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place and people were free to leave the home as they pleased.

Is the service effective?

Appropriate research and guidance was used to assess people's needs and monitor their health. The service sought input from other services when needed. This included appropriate support with specific medical conditions, nutritional needs and mobility requirements. Staff had received training to support them to meet people's individual needs. People we spoke with felt that their needs were met. One person said, "Whenever I ask for things, I always get them."

Is the service caring?

People told us that staff were polite and respectful and we observed staff responding to people in a compassionate and respectful manner. We did not see evidence that most people were involved in planning their care or that consent had been obtained for their care to be delivered as planned. However, people said their choices were respected. People told us, "The staff are lovely. They are all nice people and they really care" and "Staff are wonderful and they always have time for a joke."

Is the service responsive to people�s needs?

We saw that not everybody who needed a �mental capacity assessment� or a �best interests decision� had these made by the right people. A compliance action has been set for this and the provider must tell us how they plan to improve.

People's needs were assessed before they moved into the home and their care was planned to meet these needs. One person described how the provider had ensured they received the medical treatment they needed. Meals were planned to cater for individual needs and catering staff were aware of dietary requirements. People had enough suitable food and drinks.

Activity plans were tailored to individual preferences and we saw people participating in activities corresponding to the preferred activities in their care plans.

Is the service well-led?

At the time of our visit, there was no registered manager in place. The home's manager told us they had recently submitted an application to become the registered manager. Staff felt able to raise concerns with management and any issues were addressed quickly and effectively. The manager had identified care plans as an area for improvement and demonstrated that they were in the process of making improvements. Staff were involved in making improvements to the service.

People who used the service told us managers were approachable and "you can just knock on the door if you want to give your views."

Inspection carried out on 23 May 2013

During a routine inspection

We spoke with some of the people who use this service and they confirmed that they were happy however, they all had varying degrees of dementia and communication with them was difficult. One person using the service told us �I like it here� and �I do not have any complaint.� Another person said �The staff are lovely�.

We were informed that representatives of people using the service were in regular contact with staff at home and they also visited the home on a regular basis.

People were supported in promoting their independence and community involvement. People were given opportunities to express their choices and to make decisions in their daily lives. We observed that staff were aware of people�s preferences and routines so they could support people in their daily lives. For example they knew at what time people preferred to eat and what time they went to bed or got up. From our own observations we saw staff treated people using the service with dignity and respect.

Inspection carried out on 22 August 2012

During a routine inspection

We spoke with some of the people who use this service and they confirmed that they were happy however, they all had varying degrees of dementia and communication with them was difficult. The views of people who were able to comment on their experience can be summarised as follows "the staff are very kind and helpful" and "they are kind to me". All the people we met appeared to be happy and looked well cared for.

Inspection carried out on 10 May 2011

During a routine inspection

Overall, people we met told us that staff always treated them well and listened to what they had to say. Comments included, �they look after me well �, �the staff are good� and �I like living here�. We also spoke with a relative that was visiting who told us that the care in the home was very good and any issues that arose would be addressed promptly.

Reports under our old system of regulation (including those from before CQC was created)