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Ghyll Grove Care Home Requires improvement

The provider of this service changed - see old profile

Inspection Summary

Overall summary & rating

Requires improvement

Updated 17 February 2021

About the service

Ghyll Grove Care Home is a residential care home providing personal and nursing care for up to 169 older people. Some people have dementia related needs and some people require palliative and end of life care. The service consists of four houses: Kennett House, Medway House, Chelmer House and Thames House. At the time of our inspection there were 79 people living at the service.

People’s experience of using this service and what we found

Effective arrangements were not in place to mitigate risks for people using the service and staff employed at the service. Not all appropriate measures were in place or being followed to prevent and control the spread of infections. Effective arrangements were not in place to protect and prevent people who used the service from abuse or to properly investigate where concerns were raised.

The leadership, management and governance arrangements did not provide assurance the service was well-led. Quality assurance and governance arrangements at the service were not reliable or effective in identifying shortfalls in the service. Governance arrangements, including performance management, roles and responsibilities required improvement. Lessons were not consistently learned to improve the service for people using the service.

People were not always supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

There were enough staff available to meet people’s needs. Suitable arrangements were in place to ensure the proper and safe use of medicines.

At this inspection we found improvements had been made relating to staffing levels and the deployment of staff; and the provider was no longer in breach of Regulation 18 of the Health and Social Care Act 2008 [Regulated Activities] Regulations 2014. However, not enough improvement had been made relating to governance and the provider was still in breach of Regulation 17 of the Health and Social Care Act 2008 [Regulated Activities] Regulations 2014.

Rating at last inspection (and update) The last rating for the service was Requires Improvement, [published January 2020]. This service remains rated Requires Improvement. This service has been rated Requires Improvement for the last three consecutive inspections.

Why we inspected

This was a focused inspection based on the previous rating and prompted in part due to concerns raised by the Local Authority in July 2020. A decision was made for us to inspect and examine the risks identified by the Local Authority. A focused inspection was carried out to review the key questions of ‘Safe’ and ‘Well-Led’ only.

We also looked at infection prevention and control measures under the ‘Safe’ key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID 19 and other infection outbreaks effectively.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Ghyll Grove Care Home on our website at


We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

Inspection areas


Requires improvement

Updated 17 February 2021

The service was not always safe.

Details are in our safe findings below.


Requires improvement

Updated 17 February 2021


Requires improvement

Updated 17 February 2021


Requires improvement

Updated 17 February 2021



Updated 17 February 2021

The service was not well-led.

Details are in our well-Led findings below.