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Inspection Summary


Overall summary & rating

Good

Updated 23 December 2017

This comprehensive inspection took place on 23 and 29 November 2017 and was unannounced. The last inspection took place in January 2017 and the service was rated ‘requires improvement’ in Safe, Effective, Well Led and overall. Caring and Responsive were rated ‘good’. We found breaches of Regulations relating to safe care and treatment, consent to care and treatment and good governance. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when they would make the necessary improvements to meet regulations. During this inspection, we found that improvements had been made.

Grosvenor House is a ‘care home’ for up to six people. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. At the time of the inspection, two people were using the service.

The previous registered manager left the service in August 2017. The director, who was also a shareholder in the service, had employed a new manager who was due to begin working with the service in December 2017 and the expectation was that they would apply to CQC to become the registered manager. 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.

During the inspection we found, the provider had not been notifying the Commission of the applications they had made and the outcomes of these applications for authorisations to deprive people of their liberty under the Deprivation of Liberty Safeguards (DoLS). This was addressed promptly following the inspection and the director said this was an oversight. However, the provider's quality assurance systems had not identified that these notifications had not been submitted to the Commission as required by law.

The provider had procedures in place to protect people from abuse. Care workers we spoke with knew how to respond to safeguarding concerns. People had risk assessments and management plans in place to minimise risks and incidents and accidents were recorded appropriately.

Care workers followed procedures for the management of people’s medicines and underwent medicines training and competency testing. Weekly medicines audits indicated that people were receiving their medicines safely as prescribed.

Care workers had completed training in infection control and used protective equipment as required.

Care workers had an induction, up to date relevant training, supervision and annual appraisals to develop the necessary skills to support people using the service. Safe recruitment procedures were followed to ensure care workers were suitable to work with people using the service.

People were supported to have maximum choice and control of their lives and care workers were responsive to individual needs and preferences.

People's dietary and health needs had been assessed and recorded and were monitored.

People and their families, were involved in their care plans and making day to day decisions. Care plans contained the required information to give care workers guidelines to effectively care for people in their preferred manner.

There was a complaints procedure in place, however the service had not had any complaints since the last inspection. The director was available at the service and stakeholders told us they were approachable and supportive.

The service had a number of systems in place to monitor, manage and improve service delivery so a quality service was provided to people. This included a complaints system, service audits and satisfaction surveys.

Inspection areas

Safe

Good

Updated 23 December 2017

The service was safe.

Safeguarding and whistle blowing policies were up to date and staff knew how to respond to safeguarding concerns.

People had risk assessments and risk management plans to minimise the risk of harm. Incidents and accidents were recorded and managed appropriately.

Safe recruitment procedures were followed to ensure care workers were suitable to work with people using the service.

The provider ensured staff had the relevant training, and had audits in place for the safe management of medicines.

The provider had infection control procedures in place which were followed by care workers.

Effective

Good

Updated 23 December 2017

The service was effective.

The provider acted in accordance with the requirements of the Mental Capacity Act (2005) to promote people�s rights.

People�s physical, mental health and social needs holistically assessed prior to their move to the home.

Care workers were supported to develop professionally through an induction, training, supervision and yearly appraisals.

People's dietary and health needs had been assessed and recorded and were monitored.

Caring

Good

Updated 23 December 2017

The service was caring.

Relatives of people using the service said care workers treated their relatives kindly and with respect.

Care plans identified people�s cultural needs and preferences and provided care workers with guidelines to effectively care for people in a way that met their needs.

Care workers supported people to express their views and be involved in day to day decision making.

Responsive

Good

Updated 23 December 2017

The service was responsive.

People and their families were involved in planning people�s care. Care plans included people�s preferences and guidance on how they would like their care delivered. Reviews were held annually and involved people and their families.

The service had a complaints procedure and people knew how to make a complaint if they wished to.

People and their families were consulted about end of life care.

Well-led

Requires improvement

Updated 23 December 2017

The service was not always well led.

The provider had not always notified the Commission of events or incidents that had taken place within the service as they are required by law, in a timely manner. The director submitted the necessary notifications after the inspection.

The director was very involved in the running of the service, had oversight of it and promoted an open culture within the home.

Care workers and relatives had the opportunity to provide feedback to the provider to improve service delivery.

The provider had a number of data management and audit systems in place to monitor the quality of the care provided.

Relatives of people using the service and care workers were able to approach the director and felt supported.