Granville Gardens Care Home

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. This is the first assessment for this newly registered service. This key question has been rated 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 people’s safe care and treatment, and the ways people’s medicines were managed.

This service scored 53 (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. The manager was approachable and listened to concerns raised by people. One person told us, “I can go to the manager anytime that I want to. We have regular meetings with him.” Another person said, “They [management] take things on board, they listen to what we have to say, they’re always very good.” Staff told us how they have regular meetings following incidents. One staff member said, “We go over things, make sure everything was followed and done correctly, and what we could have done differently.”

The provider had a pre-admission procedure in place to make sure people’s needs could be met at the home. One person told us, “The manager came to see me to see what I needed when I was at home before I came here.” Records demonstrated the provider completed a full assessment with the person prior to them moving into the home.

The provider did not always work with people to understand what being safe meant to them and the best way to achieve that. We identified where people required lawful authorisations to deprive them of their liberty, there were not effective processes to monitor and follow up on the process of applications. For example, 1 person’s application required a re-submission to the funding authority as the previous application had been cancelled. This had not been identified or chased up by the provider. This meant this person had been deprived of their liberty for the purpose of receiving care or treatment without lawful authority. However, safeguarding information was available in various formats throughout the service so people knew who they could contact to report concerns. People told us they felt safe living at Granville Gardens. One person said, “I do like living here, I have everything that I need to keep me safe.

The provider had systems in place to assess, monitor and manage risks. However, some risk assessments did not consistently contain sufficient information to guide staff about the required actions to mitigate potential risks. Personal Emergency Evacuation Plans (PEEP) for people were in place. However, they were not always reflective of people's needs. For example, 1 person’s PEEP did not reflect their current mobility needs and failed to provide up to date guidance on how staff were to support the person during an emergency evacuation.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Regular maintenance checks were in place to ensure the environment was safe for people, this included Legionella testing.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. People told us they were supported by staff who were kind and caring, although feedback was mixed regarding staff responding to call bells. One person said, “I think they look after me really well. I only have to mention something, and it’s done.” However, 1 person told us, “They take a long time to come at night. This has been happening for a few weeks.” Staff had regular meetings to discuss people’s care, and supervisions to discuss their development. One staff member told us, “We use agency a couple of times a week due to staff sickness, but they [management] are really good as they can get someone quickly for us. They [agency staff] know the residents really well as we get the same staff. Staffing is fine on all the floors.”

The provider did not always assess or manage the risk of infection. We identified concerns in relation to food storage, soiled bed linen and a soiled mattress cover. The home manager took immediate action in response to this. However, we found the overall cleanliness of communal spaces and bedrooms to be good.

People were given their medicines, and this was recorded on their electronic medicines administration record (eMAR). The staff treated people with care when medicines were administered. However, people’s preferences of how they like to take their medicine were not always present on the eMAR. Medicines were stored safely and securely. However, waste medicine that needed to be returned to the pharmacy was not signed by two staff in the return book or stored securely in the clinic room. This was against the provider’s policy to stop medicines from being diverted. Fridge temperatures were recorded on most days however when the temperature went under 2 degrees or over 8 degrees, no action was evident. Recent audits had not identified fridge temperature deviations that had occurred and the possible reasons why. When medicines were given covertly (disguised in food or drink), the care plan for a person on covert medicines did not contain pharmaceutical advice from a pharmacist on how these medicines should be administered safely. When required (PRN) protocols were present for people although they were not always person-centred. Time-sensitive medicines for Parkinson disease, were observed on numerous occasions not to have been given at the right time to ensure that they were effective for people. This would have affected people’s movement and therefore quality of life. Since the assessment, the provider has been keen to rectify all issues identified from the inspection and has been responsive in doing so. However, we cannot be assured the oversight is in place to have found these findings without our involvement.