Grosvenor House

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 changed to good. This meant people were safe and protected from avoidable harm.

At our last assessment we found a breach of the regulation relating to safe care and treatment. Medicine management was unsafe, there were inaccurate records, and unassessed medicine crushing. Risk assessments were outdated or missing, and environmental safety issues, such as unrecorded missing equipment, were not properly addressed. At this assessment we found improvements had been made and there was no longer a breach of regulation.

This service scored 75 (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 detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The registered manager carried out regular walkarounds and dealt with any concerns promptly. Staff completed routine health and safety checks, including fire safety, water temperature, and equipment servicing. Any issues were logged and acted on quickly.

Personal Emergency Evacuation Plans (PEEPs) were in place for each person using the service. The provider had appropriate plans in place to evacuate people in case of an emergency.

This proactive approach to environmental safety was clear. Staff kept detailed logs of incidents. They reviewed accidents quickly. Staff worked with families and professionals to fix problems. Risks were managed well.

Emergency signage was visible. Staff knew the evacuation procedures and described them confidently when asked. Mobility aids and equipment were stored safely and in good condition.

We found a gap in risk assessment documentation for people who refused window restrictors. The relevant care plans did not record this decision or the person’s capacity to make it. We requested clarification to confirm whether the provider had obtained appropriate consent or put further safety measures in place. We kept the Safe Environments section at a score of 2 until we receive confirmation.

The provider worked with people, their representatives and external professionals to establish systems of care that kept people safe while recognising their preferences, routines and ways of communicating. They made sure there was continuity of care, including when people moved between different providers.

Where people had multiple needs, such as not being able to use words to communicate or they were at risk of falls, seizures or self-harm, support plans were detailed and regularly updated to reflect behavioural cues and specific actions needed to reduce distress. For example, where people used a range of unique physical expressions to indicate their needs or preferences. Staff used this knowledge to engage people in decisions about daily routines and transitions, ensuring they were prepared and emotionally supported during changes.

Staff gave people advance notice and used consistent language and reassurance to reduce anxiety. When people needed to access healthcare or to leave the home, their mobility risks and sensory preferences were considered, and tools were used to maintain calm and familiarity.

Staff were encouraged to advocate for people and liaise with healthcare providers to ensure reasonable adjustments were in place.

For example, when staff arranged medical appointments or treatment reviews, they considered people’s communication needs. They also looked at any risks linked to unfamiliar places. Keeping the same keyworker involved helped reduce disruption and build confidence.

This personalised, joined-up support helped people move safely between services. It also helped them keep their dignity, independence, and emotional wellbeing, especially for those who had difficulty with communication or movement.

The provider worked closely with people and healthcare professionals to understand what safety meant to each individual and how to achieve it in a person-centred way. Safeguarding was embedded in the culture of the provider, with staff supporting people to live fulfilling lives while being protected from harm.

People’s right to live free from abuse, discrimination, and neglect was upheld. Staff were trained in safeguarding and confident in recognising and reporting concerns. Where risks were identified staff acted swiftly and sensitively. Measures were put in place to reduce distress and prevent potential abuse.

Restrictive practices were only used when necessary and always as a last resort. These were clearly documented in behaviour support plans, regularly reviewed, and proportionate to the risks. Staff were trained to offer choices, use distraction, and adapt communication to reduce distress and avoid escalation.

Where safeguarding risks were raised, collaborative plans were implemented to protect people while maintaining important relationships with relatives.

Staff respected people’s autonomy while ensuring safety. This included supporting people with limited communication to express distress through body language, using sensory tools to promote wellbeing, and helping people understand routines and transitions at their own pace. Where restrictive elements were in place, for example, guided mobility or covert medication, these were carefully documented in line with mental capacity assessments and best interest decisions.

The provider responded openly to safeguarding concerns and worked with the right agencies, learning from what happened, and changing support to meet people’s needs. People were kept safe while still being supported to stay independent and be themselves.

The provider 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.

At our last assessment, risk assessments had been out of date or missing. At this assessment, we identified that risks were now consistently assessed, regularly reviewed, and clearly documented. Staff acted on new or changing risks promptly, with input from relevant professionals where needed.

Staff supported people to stay safe without restricting their independence. One person told us, “[Staff] are here to help me, but they don’t make me do things.” Staff held daily meetings and regular reviews with people and their families to share updates, review risks, and make joint decisions about care.

Staff managed risks well by acting early and responding quickly. For example, when choking risks were found, they followed advice from speech and language therapists and used guidelines for safe eating and drinking. Behaviour support plans and pain detection tools helped people who were not able to use words to communicate and express what they needed.

Where risks were present, staff worked with people and their families to put practical, person-led safeguards in place. These included environmental changes, enhanced monitoring, use of technology and financial adjustments that allowed people to stay safe without losing their sense of freedom or control.

Where people had experienced incidents, staff worked with relatives and professionals to update care plans and introduce safer, tailored measures. These included door sensors, fall-prevention equipment, and personal support strategies, all focused on the least restrictive options.

Staff learned from incidents, such as medicines errors, by improving supervision, carrying out retraining, and introducing daily spot checks. These actions strengthened safety without limiting choice.

Care plans and risk assessments were regularly reviewed using a digital system, ensuring up-to-date and person-centred support. Staff used positive, respectful language and supported people to take informed, positive risks as part of living a full life.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The registered manager carried out regular walkarounds and dealt with any concerns promptly. Staff completed routine health and safety checks, including fire safety, water temperature, and equipment servicing. Any issues were logged and acted on quickly.

Personal Emergency Evacuation Plans (PEEPs) were in place for each person using the service. The provider had appropriate plans in place to evacuate people in case of an emergency.

This proactive approach to environmental safety was clear. Staff kept detailed logs of incidents. They reviewed accidents quickly. Staff worked with families and professionals to fix problems. Risks were managed well.

Emergency signage was visible. Staff knew the evacuation procedures and described them confidently when asked. Mobility aids and equipment were stored safely and in good condition.

The provider ensured there were enough qualified, skilled, and experienced staff in place, who received effective support, supervision, and development. Staff worked well together to deliver safe care tailored to people’s individual needs.

Staffing levels and competencies were regularly reviewed to maintain safety. Staff had routine supervisions and annual appraisals, providing opportunities to reflect on their practice, raise concerns, and identify learning and development needs. A colleague ambassador had been introduced. This is a staff member chosen to represent and support their team. They helped share ideas, promote good practice, and act as a link between staff and management

New staff completed a structured induction, including shadowing experienced colleagues, and worked towards the Care Certificate where appropriate. All staff received regular medicines competency assessments and annual refresher training to maintain safe practice.

Care workers were trained to manage risks and understood how to meet people’s health and support needs, including safe administration of medicines, the use of assistive equipment, and responding when people expressed distress using positive behaviour support tools. This ensured care remained consistent and person-centred. A care worker told us, “We offer a good quality of care to everyone.”

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.

Since the last assessment, infection control arrangements had improved significantly. Previously, there had been inconsistent cleaning and staff did not follow hygiene protocols. These were addressed with updated training, stricter cleaning schedules, and regular audits to ensure compliance with current guidance. Staff now consistently followed best practice, keeping the environment safe and healthy.

Risk assessments were personalised with input from district nurses, who advised on infection control measures. Staff used PPE properly and maintained good hygiene.

The environment was clean, well-maintained, and free from odours. Managers completed monthly infection control audits and routine observations to monitor standards.

These steps helped prevent infections and ensured the setting remained safe and clean.

Cleaning schedules were up to date, and staff followed infection prevention and control guidance, including correct use of personal protective equipment. People were supported to maintain clean and comfortable personal spaces. A person we spoke to said, “Staff help me keep my room clean.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

At our previous inspection, we identified a breach of regulation in relation to medicines. There were errors in stock, inappropriate crushing without assessment, and inconsistent risk management for conditions like epilepsy or diabetes.

At this assessment we identified that medicines were now securely stored and administered following full assessments. Staff completed annual competency checks, and digital tools, for example, blood glucose tracking tools and provided supportive and proactive care. Care plans for diabetes, epilepsy, and choking now included clear daily management strategies.

Medicines were now managed safely, with regular audits and accurate records. Staff followed protocols for safe administration, including assessments where medicines prescriptions were changed. Risk assessments were detailed, person-specific, and updated promptly after incidents. Environmental checks were routine, and any missing equipment or alternatives were clearly recorded in care plans.

Staff made sure people received their medicines safely and in a way that suited their needs, preferences, and abilities. People were involved in decisions about their medicines, including any changes. Where possible, staff supported people to take medicines independently.

If someone could not understand or manage medicines, a personalised care plan detailed the support they needed. For example, where medicines had to be administered covertly, this was agreed through best interest meetings with input from relatives and health professionals and reviewed regularly.

Care plans also covered how and when to take medicines, including any cultural or dietary needs. They were checked regularly by professionals.

One person used a pain detection app to help staff understand their pain better. It detected facial expressions which provided information to staff as to how the person was feeling. This helped staff avoid giving unnecessary medicines. Another person was supported to eat healthier after staff worked with healthcare and safeguarding teams. This helped reduce their insulin needs safely.

PRN (as required) medicines were used appropriately. Care plans clearly stated when and how they should be given. Staff recorded their use, checked if they worked, and looked for patterns to ensure they were not overused. PRN protocols were reviewed regularly with healthcare professionals to ensure they remained appropriate and person-centred.

Medicines safety was a priority. Staff followed strict procedures to prevent errors. They handed over information daily and carried out weekly medicine checks. A pharmacist conducted medicine reviews every 6 months. The registered manager audited controlled drugs monthly. Staff received regular training and had their competency checked annually.

Homely remedies and complementary treatments, like essential oils, were used safely with clear protocols and best interest decisions. All medicines, including these remedies, were stored securely and accessed only by trained staff.