Grove House Home for Older People

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 our last assessment we rated this key question requires improvement. At this assessment 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.

The service was in breach of legal regulation in relation to managing medicines safely.

This service scored 62 (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 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 to continually identify and embed good practice.

The provider had a clear system to manage incidents. Staff completed incident forms appropriately and these were monitored by managers. Themes and trends were discussed at regular governance meetings. The provider analysed issues such as falls and had made improvements regarding their post falls practices following the previous inspection. Staff had good knowledge about how to identify concerns and report these appropriately.

The provider 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.

Staff made referrals to other agencies and information was shared appropriately to make sure there was continuity of care. There were robust pre-admissions processes and policies to make sure staff had important information and guidance about how to support people according to their needs.

The provider 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. The provider shared concerns quickly and appropriately.

The provider had an up-to-date safeguarding policy and information about safeguarding processes was easily accessible to staff. Staff completed safeguarding training regularly and knew what to do if they had any concerns. The manager monitored safeguarding alerts and made sure any recommendations following investigations were implemented.

The provider did not always work well with people to understand and manage risks in a timely way. Staff had good knowledge about people’s needs during periods of distress.

The manager conducted risk assessments, and most were reviewed monthly. We found that due to the provider’s policy, some risk assessments were only reviewed every 3 months. We found discrepancies in some people’s risk assessments. For example, although staff had good knowledge about a person's nutritional needs, the information contained in their diet and nutrition risk assessment differed to the information in the choking risk assessment as it had not been reviewed. This could cause confusion for staff about how to manage risk. We fed this back to the provider who updated the information immediately.

Staff understood how to support people if they were experiencing distress and recorded any observations about what may have affected someone’s mood to reduce the risk of this happening again in the future. People and their relatives were involved in thinking about how to manage their risks.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

All health and safety checks had been made, and we saw compliance certificates including gas safety and fire safety. There was a system to manage the maintenance of the building and premises. The shower in the 1st floor communal bathroom was out of order and had leaked into the ground floor bathroom. The provider planned a full refurbishment to commence 15 October 2025.

There were enough staff to meet people’s needs, however there were key times of the day where staff were under extra pressure, meaning people had to wait longer on occasion. There were safe recruitment processes and staff completed relevant training to make sure they had the right knowledge and skills.

Care staff administered medicines alongside supporting people with personal care; some people required 2 members of staff to meet their mobility needs. Staff also completed some domestic tasks. People said at times they had to wait; 1 person said, “The staff look after us well. Sometimes they are a bit pushed, and we have to wait for tablets.” Another person said, “Sometimes the staff are under pressure especially in the mornings.” We observed that staff were continuously interrupted during medicine administration which could increase the risk of mistakes being made. We also noted there was limited activity in and outside of the home. A person told us, “I have never been out of the home except for hospital appointments. A walk, even just around the home, would be good. My family had to provide my entertainment with books, crafts and knitting.” Another person said, “I spend a lot of time in my room, so I don't do many activities. I would like some company occasionally.” A third said, “I do feel lonely sometimes. I would just like the time to be available to have a chat with the staff. I would probably join in some activities if we had some.” We fed this back to the provider who said they were recruiting more activities co-ordinators.

Staff were recruited using safe processes, and checks were made. For example, references and disclosure and barring (DBS) checks. Staff completed training at regular intervals including training around learning disabilities.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

There were cleaning and housekeeping staff who managed cleaning schedules and rotas well. The home was clean and comfortable, and people and their relatives said the hygiene and cleanliness was maintained to a high standard. A person said, “My room is nice and always cleaned for me.” Managers completed cleaning audits and made sure staff wore PPE when required.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

We found gaps in the recording of medicines. Staff did not always sign to say they administered medicines as per the prescription, and some people’s stock did not always balance against what was expected. Staff did not record the amounts of thickener they added to drinks for people who were at risk of choking. Thickener is added to drinks to reduce the risk of choking; incorrect ingestion could pose a risk to people’s health. Therefore, we were not assured people received the correct doses of their medicines to manage their health needs safely.

At times information around ‘as and when required’ medicines was missing in order to guide staff appropriately. When information was in place this was not always person centred.

Storage of medicines was not always managed appropriately. We found temperature monitoring of areas used to store medicines was not always recorded. Most medicines were stored securely, however we found some prescribed creams were not locked away, as per guidelines.

Although the service was carrying out audits related to medicines management, they had not always identified issues found during the assessment.

We fed our findings back to the provider who acted immediately to address. Actions included daily checks of medicines records and stock levels.