Grace House Care Home Limited

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 Good. At this assessment the rating has changed to 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 safe care and treatment and the way people’s medicines were managed.

This service scored 59 (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.

Although the registered manager told us accidents and incidents were recorded, analysed for themes and trends, and learning shared with staff, records were not always complete. We found staff did not consistently record whether people sustained injuries, were taken to hospital, or the outcome of incidents.

While the registered manager completed monthly analyses of accidents and incidents, incomplete records meant these may not have been comprehensive. Analysis of themes and trends was also insufficient. For example, 1 person experienced 5 night-time falls over 5 months, but this pattern had not been identified or acted on to reduce the risk of further incidents. However, some trends had been recognised, resulting in actions such as moving people to downstairs rooms and referring 1 person to their GP following several falls.

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.

The registered manager gathered information about people from different sources prior to them moving into the service. This helped ensure people were not asked numerous questions about their care needs. Relatives told us they were involved in this initial stage of their family member moving into Grace House Care Home. They said they provided all of the information needed to the service. Relatives said the service was communicative and would contact them if they required healthcare professional involvement which meant relatives were kept up to date with their family member’s care and their family member was not asked to provide information when they may not be in a position to do so.

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 service had systems in place to protect people's rights under the Deprivation of Liberty Safeguards (DoLS).

The registered manager and staff understood their responsibility to report any allegations of abuse to the local authority safeguarding team. Staff had received safeguarding training and this was refreshed regularly to ensure they were following good practice and able to recognise potential signs of abuse. A staff member told us, “If something didn’t sit right with me, I’d report it to [registered manager] or CQC."

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We found risks to people's health and safety were not always effectively managed, with care plans and risk assessments not consistently followed.

Air-flow pressure-relieving mattresses were not always set correctly to protect people's skin health. For example, 1 person's mattress was set to 75kg despite them weighing 50.8kg, this meant there was an increased risk of skin damage. Care plans relating to nutrition were also not consistently followed. One person who required a fortified diet and fortnightly weight monitoring was not included on the kitchen's fortified diet list and there was no evidence they had been weighed as stated in their care plan. Another person had lost 7kg since moving into the service but had only been weighed twice which meant staff were not robustly or consistently monitoring this person for further weight loss. We also found trip hazards from call bell and sensor mat wires trailing across 1 person's bedroom floor, and 1 person's medication records did not explain why they had been prescribed some medicines. This information would help understand the person’s medical needs better and how they may present themselves to the person.

However, staff had identified and managed some risks appropriately. For example, they monitored people at risk of constipation and provided medicines when needed, and 1 person's falls risk assessment included the use of a sensor mat and ensuring their call bell was within reach.

People generally said they felt safe and told us, “I absolutely feel safe. I never feel I would be forgotten”, “I have no concerns in that respect” and “Safe – yes, but when I’m waiting for bed it’s not good.” Relatives reiterated these views by saying, “I feel my mum is safe” and “We have no worries about her safety.”

The provider did not always detect and control potential risks in the care environment.

There were areas of the environment that required repair or maintenance. In 1 bathroom, the shower was out of service and the raised toilet seat did not fit securely on the toilet. Raised toilet seats must fit correctly on the toilet bowl to prevent movement or tipping, which could result in serious falls or injury.

We also saw large vases stored on open shelving in one corridor, creating a potential hazard and in various parts of the premises the skirting or door frames were heavily chipped or damaged. People deserve to live in a dignified, well-kept and maintained environment.

However, other parts of the service had been made safe. Following an inspection by the fire service, improvements had been made to ensure the building met the required fire safety standards. These included installing a new fire alarm system with alarms in every room and modifying doors to make them compliant. We found each person had a personal evacuation plan readily available for the emergency services should it be needed and regular environmental safety checks were carried out, including routine water testing for Legionella.

Relatives were happy with the environment, with 1 telling us, “I am happy with Mum’s room. She has a sensor mat – she used to wander a lot – and they seem to address things through the maintenance man.”

The provider did not always make sure there were enough qualified, skilled and experienced staff appropriately deployed around the service. They did not always make sure staff received effective supervision.

Although there were enough staff on duty throughout our visit, staff deployment needed to be reviewed as our assessment found it insufficient to meet people’s needs and ensure people received timely support. Some people told us they had to wait in a "queue" to be assisted to bed. People said, "Not enough staff to get me to bed. I have to wait and I'm tired. It's a queue system" and “It’s not easy to get to bed. You have to queue up. What annoys me is why do I have to stay up.” Following our visit, the provider informed us they had added an additional shift to support people to bed in the evening. Our review of daily records also showed some people were supported to the dining room for breakfast any time between 08:30 and 11:15, meaning on some occasions people were only eating breakfast an hour before lunch was served. This suggested staff were either insufficiently deployed during the morning and evening or there were not enough of them for these parts of the day.

We also observed at lunchtime, 1 person who was asleep. Staff had placed their meal in front of them but as staff were supporting other people no one was available to wake up or encourage the person to eat. This resulted in their meal remaining untouched for at least 15 minutes and would likely have been cold by the time they were able to eat it.

People and relatives had mixed views about staffing telling us, “Depends who is on. Sometimes you have to wait. Feels like a long time, but it’s probably not”, “I think there is enough”, “Usually (enough) but not always. On the whole though there is plenty”, “Not enough of them and so much agency. They don’t know you” and “I feel there are enough staff.”

We had similar views from staff who said, “We had a meeting last week to say there were not enough staff. Some people want person-centred care. Some want attention and we can’t give it”, “It depends on who is working. Some days it’s fine. Others it’s not”, “Staffing varies. If staff cancel, it can be stressful. We have a good team though. People may wait in the morning.”

Staff did not always receive regular supervision or one-to-one meetings with their line manager. The registered manager told us, "Supervisions are not done as often as we like. We are behind. It is something we are very aware of." As a result, staff may not always have opportunities to discuss their role, raise concerns, or identify training needs.

Recruitment processes were not consistently robust. One staff member had started work without a current Disclosure and Barring Service (DBS) check, and another did not have a complete employment history on file. We raised this with the registered manager, who took immediate action to address these issues.

However, staff received training for their role and told us the training was very good. One staff member said, “The training was pretty good. I had not had much experience before. It made me able and staff and colleagues supported me. I’m now confident.” In addition, staff carrying out medicines administration were competency checked.

The provider did not always assess or manage the risk of infection sufficiently.

Although an infection control audit was conducted this did not include questions about the cleanliness of the premises, instead it focussed on staff practice, policies and training. This meant the registered manager had not identified areas in the building that were not clean or could not be cleaned appropriately. This included bare wood radiator covers, chipped and damaged skirting and door frames, missing bathroom tiles, bubbling paint on windowsills and degraded or ill-fitting linoleum flooring in bathrooms and en-suites. This shortfall meant an increased risk of avoidable harm and infection for people.

The laundry room was not fit for purpose. There were no handwashing facilities for staff and insufficient space to maintain clear separation between clean and dirty laundry. We observed bags of clean and soiled clothing stacked together, and a staff member handling soiled laundry without wearing gloves. There was also a persistent malodour in the main communal areas.

We discussed our observations with the registered manager and a member of staff member of staff told us, “I have done an audit myself, so I know which areas need to be addressed immediately. I have carried out a deep clean of the lounge and provided the maintenance person with a list of changes needed to support effective cleaning. I am rearranging the laundry room and creating a segregation area for the sluice, and I am getting rid of the support cushions in the lounge as I have identified the smell of urine is coming from them.”

Following the inspection, the registered manager provided evidence that remedial action had begun.

The provider did not always ensure medicines and treatments were managed safely or in line with people's needs, capacities and preferences.

Medicines administration at the service was slow, which increased the risk that medicines were not always given at the prescribed times. At 10:20am, we observed a staff member carrying out the morning medicines round. They told us, "The round is actually between 07:30 and 10:00," but it was not completed until almost 10:45am. Another staff member also told us they did not usually finish the round at 10:30. This created a risk that lunchtime medicines could be administered too soon after morning medicines or later than prescribed. The service's electronic medicines administration system helped reduce this risk however by preventing medicines from being given inappropriately.

Staff did not always record the exact administration time for time-critical medicines, such as medicines to treat the symptoms of Parkinson’s disease. We found one person had received this medicine at varying times between 7:32am and 10:20am over a 6-day period. This meant the service could not be assured these medicines were given consistently and people were not affected adversely by their symptoms impacting on their quality of life. Medicines Administration Records (MAR) were not always accurate or complete. For example, there was an unexplained gap in 1 person's medication record. In addition, although the service's medicines audit stated all people prescribed 'as required' (PRN) medicines had protocols in place, we found 2 people did not have guidance for all of their PRN medicines. This meant the service could not be assured they were being administered consistently.

The service was not following its medicines policy for monitoring medicine trolley temperatures. The policy required temperatures to be checked and recorded daily, with the registered manager informed immediately if they exceeded 25°C. During the inspection, 1 trolley was recorded at 27°C and another at 26.5°C, with no evidence this had been escalated. Temperature records were also inconsistent, with no entries on 8 of the previous 42 days. Staff checked temperatures only once each day, meaning any rise above safe levels later in the day may not be identified.

Following the inspection, the registered manager provided evidence of the actions taken to address these concerns. This included recruiting a second staff member to support with medication administration in the morning to help ensure people received their medicines in line with their prescription.