Archived: Grosvenor Hall

Updated 8 September 2020

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 Care Act 2014.

Inspection team

The inspection was carried out by one inspector.

Service and service type

Grosvenor Hall is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

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 as well as recent safeguarding concerns that had been raised. We sought feedback from the local authority and other professionals who worked with the service. We used all of this information to plan our inspection. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.

During the inspection

We spoke with two people who used the service, the care manager who was providing management cover, a team leader, two care staff and two agency staff workers. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We reviewed a range of records. This included nine people’s care records in part and five medication records. We looked at four staff files in relation to supervision and training. We also looked at records relating to the management of the service, including staff rotas.

After the inspection

We continued to speak to the local authority and other professionals who were regularly visiting the service. As a result of what we found on the inspection visit, we raised further safeguarding concerns with the local authority for investigation. We continued to communicate with the provider to ensure the safety of people.

Updated 8 September 2020

About the service

Grosvenor Hall is a residential care home providing personal care to people with dementia. The service can support up to 23 people in one adapted building. At the time of this inspection, 12 people lived at the service

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

Risks which affected people's health, safety and wellbeing were not always documented. This meant that staff did not always have adequate information to manage and mitigate risks to people. Accidents and incidents had not been thoroughly recorded and action had not been taken to reduce risks. People had not been provided with sufficient fluids and their weights were not monitored to highlight any concerns.

Safeguarding concerns had not been reported by staff and management. Staff were not clear of their roles and responsibilities in relation to safeguarding.

The service did not have sufficient infection prevention and control measures in place. Government guidance in relation to COVID 19 had not been followed.

Medicines had not been managed safely. Staff had not received appropriate training and competency assessments. Guidance from other professionals had not been followed.

Agency staff were not familiar with people and their needs. Agency profiles were not in place and they had not been provided with an induction into the service.

For people who had care plans and risk assessments in place, these only contained basic information. They had not been updated when changes in people’s needs occurred. Some people did not have any care plans and risk assessment in place.

There was a lack of quality assurance processes in place to monitor the quality and safety of the service. There was a clear lack of provider oversight and they had not ensured effective and competent management was in place. Records that contained personal information had not been stored appropriately.

For more details, please see the full report which is on the Care Quality Commission website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (report published 19 October 2019.)

Why we inspected

We received concerns in relation to management of the service and the quality of care and support that was being provided. There had been a number of safeguarding concerns raised by other professionals. As a result, we carried out a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from requires improvement to inadequate. 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 Grosvenor Hall on our website at www.cqc.org.uk.

Enforcement

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.

We have identified breaches in relation to the safety of people and the risk of harm. We also identified breaches in relation to the management and monitoring of the service, person-centred care and nutrition at this inspection.

Because of the serious concerns relating to people’s welfare and safety we have taken enforcement action to prevent the provider from operating a regulated service at this location.