Background to this inspection
Updated
9 January 2024
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.
As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
This inspection was carried by 2 inspectors and a medicines inspector on day 1 and an inspector and medicines inspector on day 2.
Service and service type
Grace Lodge Nursing Home is a 'care home'. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Grace Lodge is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Registered Manager
This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
At the time of our inspection there was a new registered manager in post.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used all of this information to plan our inspection.
The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make.
During the inspection
We spoke with two people who used the service and four relatives about their experience of the care provided. We spoke with seven members of staff including the manager, director, clinical lead, senior care workers and care workers.
We reviewed a range of records. This included four people's care records, and nine people's medication records. We looked at staff files in relation to recruitment. A variety of records relating to the management of the service, including policies and procedures were reviewed.
Updated
9 January 2024
About the service
Grace Lodge Nursing Home provides accommodation and nursing and/or personal care to up to 65 people over 2 floors. At the time of our inspection, there were 23 people using the service.
People's experience of using this service and what we found
We found the service had made some improvements in the management of medicines since the last inspection, however they had not addressed all of the issues and further improvements were still required.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
The culture of the service was open and transparent. The registered manager and Director engaged with the inspection positively and were committed to making any necessary improvements.
The registered manager and staff had a clear understanding of their roles and responsibilities. The providers systems and processes were used effectively to measure and improve the quality and safety of the service. The registered manager promoted a positive culture which was person-centred, open, and inclusive which led to good outcomes for people. There was good working partnership with others to make sure people received all the care and support they needed.
People's relatives told us staff at the home were attentive to people’s needs and communicated well any changes to people’s care needs. Staff were kind, patient and respectful towards people and dignity and independence was promoted. People and relevant others were involved in decisions about the care provided. Staff members told us they enjoyed working at Grace Lodge; Lodge; they felt appreciated and well supported by the registered manager and provider.
People had care plans in place which were person centred and accompanying risk assessments which enabled staff to care for them safely.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update.
The last rating for this service was Inadequate (published 17 March 2023).
The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.
This service has been in Special Measures since [17 March 2023]. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.
Why we inspected
We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the key questions safe, effective, and well-led which contain those requirements.
We 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.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from Inadequate to Requires improvement. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Grace Lodge Care Home on our website at www.cqc.org.uk.
Enforcement and Recommendations
At this inspection we found a breach of regulation 12 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The breach related to the failure to ensure medicines were managed safely.
You can see what action we have asked the provider to take at the end of this full report.
Full information about CQC's regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
Follow up
We will work alongside the provider to understand what they will do to improve the standards of quality and safety and liaise with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.