Grace House Care Home Limited

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question Good. At this assessment the rating has changed to Requires Improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance at the service.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Although the provider had a shared vision, strategy and culture based on transparency, equality, diversity and inclusion, and the needs of people and their communities, we observed some practices that did not consistently meet a person-centred approach. This included people waiting to go to bed, the blanket approach to people being in the lounge and the lack of individualised activities.

However, it was evident the registered manager and staff wished to provide good care to people as they responded immediately to any shortfalls we identified, sending us evidence and action plans for moving forward.

The registered manager regularly checked on staff to help ensure they were meeting their expected standards. They told us, “I go across (into the service) regularly throughout the day. I carry out observations and speak to staff and residents. I have a good relationship with the families, and I will always be open and transparent. I look for staff who have an energy and passion about care, a nice manner about them and someone who is not averse to taking direction. I need team players who are willing to work hard to make sure people receive the care they deserve.”

Although the provider had inclusive leaders at all levels who understood the context in which they delivered care continued development of the skills required to ensure good governance and monitoring systems was needed.

Although we received positive feedback from people, relatives and staff about management we found leadership oversight was not always effective to ensure shortfalls were identified and acted upon. However, during and after our visit, the registered manager and provider were clear they wished to address these areas and ensure people were placed at the centre of their support going forward.

However, comments and feedback we received reflected the commitment the registered manager had to the service and the people they cared for. They included, “They (manager) come in at times and help out. This place suits me. I chose it. It wouldn’t suit everyone”, “Generally it’s a really lovely caring place. They do their best to give them a good life”, “The home has a real family feel and mum often believes the staff are friends or family. As a family we were really worried what would happen when mum needed residential care, but we are really happy she is in the right place and hopefully she will remain there for the rest of her life” and “We have contact with the manager. She is very good.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff felt valued, supported and comfortable at the service enabling them to feel confident should they wish to speak up. They told us, “Of course, I am able to speak up”, “I will always speak up in meetings” and “I would speak up and I would feel listened to.”

When staff raised things, they felt listened to. We were told, “The manager, she listens. Things are done immediately. She is supportive and hands on” and “The RM is approachable and listens.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The registered manager did not discriminate when recruiting new staff. They told us, “I am happy to do training to support staff into the role.” Staff told us they felt equally treated and if they were short on staffing levels on any shift, agency staff were brought in to support them.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Although there was a range of audits taking place in the service, these systems and processes were not effective as they had not identified the shortfalls we found, such as the poor maintenance in parts of the building, infection control issues, poor storage of medicines and the lack of consistent monitoring of risks relating to people.

The registered manager told us, “We’ve had 2 mock inspections since I’ve been in the role. We also audit a wide range of aspects of the service, have resident of the day and we use an electronic governance system. There are so many audits, I feel like I am doing too much and that was what I was told at my last mock inspection.”

Some audit information was contradictory. We reviewed the July medication audit and found actions which should have been completed in May were still recorded as outstanding. However, in a latter part of the audit it was recorded the actions had been completed.

We discussed this with the registered manager on our visit. Immediately following our inspection, they sent us an overarching action plan detailing how they were going to address any shortfalls as well as they general improvements they planned to strengthen their systems and processes and as such, help ensure people received consistently good care.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The registered manager and staff worked with the dentist, chiropodist, district nursing team, GP, dementia specialist and mental health team. This included collaborative working with NHS partners to introduce initiatives into the service helping to support prompt and robust monitoring of people. The registered manager was a member of the National Care Association and the Surrey Care Association.

The registered manager told us they had links with local day centres, singers, entertainers, local churches and mini-bus firm. These enabled them to arrange internal and external activities for people and gave them the opportunity to go into the local community.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

Although there was a drive on the part of the provider and registered manager to continuously improve the service, without robust governance arrangements in place they were failing to identify areas requiring improvement. However, the registered manager was extremely responsive to our feedback on the day and immediately started to take action to address our concerns, sending us evidence of actions completed and those in progress. The registered manager told us, “Every day is a learning day. There were already things we are addressing or things that we can learn from.”

The registered manager held a Grace House improvement plan which had good detail and clear evidence where matters had been addressed, discussed with staff or were still outstanding. However, the plan, actions and progress against the actions were not dated which meant it was unclear when additional actions had been added to the plan or what the timescales were for completion.

Following our site visit the provider and registered manager met to discuss our findings and they developed a further initial improvement plan to address the identified areas. Telling us, “Several of the proposed improvements are already underway, and this will be an ongoing process to ensure greater consistency, accountability, and continuous improvement across the team.