CQC report explained · a residential care home
What the CQC found at Grasmere Lodge
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, June 2022
Requires Improvement; inspectors found kind care and safe medicines, but fire risks, building repairs, recruitment checks and management oversight needed improvement.
This was an unannounced inspection carried out on 28 April, 6 May and 19 May 2022. One inspector spoke with six people, a relative, the manager and staff. They reviewed care records, medicines records, staff files and management checks.
People said they felt safe and described kind, compassionate staff. There were enough staff, medicines were managed safely, infection control measures were in place and accidents were reviewed for learning.
However, some risk assessments did not explain how people would be kept safe. Fire arrangements for people smoking in bedrooms or not leaving when the alarm sounded needed improvement. Building repairs had been delayed, and recruitment records were incomplete.
The overall rating was Requires Improvement. Safe and Well-led were both rated Requires Improvement, down from Good at the previous inspection. The provider breached Regulation 17 because its checks and oversight did not identify or address important problems.
Enough staff
Inspectors found there were enough staff on duty and no agency staff were needed.
“There were enough staff on duty and no agency staff were needed.” from the report
Safe medicines
Medicines records were completed properly, and instructions for medicines given when needed were clear.
“Medicine administration records were completed appropriately.” from the report
Positive relationships
People described positive relationships with the manager and staff. Staff also worked well with health and social care professionals.
“People told us they had a positive relationship with the registered manager and staff.” from the report
Infection control
Inspectors were assured that the home had arrangements for preventing and managing infection outbreaks, including safe use of protective equipment.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Incomplete risk assessments
seriousOne person was at risk of serious injury, but there was no risk assessment covering the relevant behaviour and actions needed to keep them safe.
“For instance, one person was at risk of serious injury because their behaviour could adversely effect their physical health.” from the report
Delayed building repairs
needs fixingRepairs had been delayed and there was no expected start date. Water could continue to leak under flooring after repeated flooding.
“The nominated individual told us they were aware work was needed however this had been delayed as they were unable to get a builder.” from the report
Recruitment records
needs fixingSome staff files did not contain full employment histories, interview records, current photographs or references that matched the application forms.
“Recruitment practices did not always meet the legal requirements.” from the report
- 01What has been done to assess and reduce the risk for people who smoke in bedrooms or may not leave when the fire alarm sounds?
- 02Have the damaged ceiling, shower room flooring and sealant been repaired, and when was this work completed?
- 03Which person did not have a risk assessment for behaviour that could affect their physical health, and is that assessment now in place?
- 04How have staff recruitment files been checked and updated to include employment histories, interview records, photographs and suitable references?
- 05What new audits and action plans are now used by senior management, and how often do they visit the home?
This was an unannounced focused inspection of Safe and Well-led; the other ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 16 June 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, November 2018
Rated Good; inspectors found safe, kind and well-managed care, but noted hygiene, activities and some support plans needed improvement.
This was an unannounced comprehensive inspection on 9 October 2018. Inspectors observed the home, spoke with eight people and three support workers, and reviewed care, medicines, staffing and management records.
The home supported 12 people at the time, with space for up to 20 people with mental health needs or related conditions. People told inspectors they felt safe, respected and listened to. Inspectors found safe medicines systems, suitable staffing, helpful staff and good support with health, food and daily life.
There were some areas to improve. Hygiene and parts of the building needed attention. People wanted more activities and trips out. Some support plans did not explain clearly enough how staff should help people build independence.
The home was rated Good in all five areas. A breach about keeping the building improved from the previous inspection had been resolved, so the home was no longer in breach of that regulation.
People felt safe
People told inspectors that staff responded quickly and helped them feel safe. Staff understood safeguarding procedures and had completed training.
“Staff always make me feel safe” from the report
Kind and respectful care
Inspectors saw friendly, patient and personalised support. People were involved in everyday decisions and staff respected their privacy.
“Staff are kind and caring and willing to offer support when I need it.” from the report
Good health and food support
People were helped to attend health appointments and their nutritional needs were monitored when needed. Menus reflected people's choices and dietary requirements.
“You never get the same food and if you don't like what's being made you can have something else” from the report
Improved management
The previous breach about building improvements had been resolved. The provider used audits, meetings and feedback to monitor the service.
“At this inspection we found improvements had been made to the environment and the service was no longer in breach of its statutory requirements.” from the report
Hygiene and building condition
needs fixingInspectors found a bad smell, a stained entrance carpet and wear and tear in some ground-floor areas. The provider said these issues were being addressed after the inspection.
“Improvements were required to hygiene in some areas of the home.” from the report
Smoking arrangements
needs fixingSeveral people smoked in their bedrooms. Inspectors said the risk was managed but highlighted the increased fire risk because there was no ventilated smoking room inside the home.
“A designated smoking room with ventilation was not available on the premises but a covered smoking area was available outside” from the report
Limited activities
minorPeople had some outings and activities but most said they wanted more choice and variety. The provider said people were being consulted about this after the inspection.
“However, most people said they would like more opportunities for activities and trips out” from the report
Independence plans
needs fixingSome support plans did not explain clearly what staff should do to help people learn or relearn skills. This could make consistent support for independence harder.
“Support plans did not detail the advice and guidance provided by staff to help people re-learn or learn new skills” from the report
- 01What hygiene, carpet and building repairs were completed after the inspection, and how are these checked now?
- 02What is the current arrangement for people who smoke, and how is the fire risk managed?
- 03What new activities, hobbies and trips are now available, including options for people who wanted to return to interests such as football or use a computer?
- 04How do current support plans explain the practical help staff provide to build or regain independence?
- 05How many domestic staff are now employed, and how has this affected the time support workers spend with residents?
This was an unannounced comprehensive inspection covering the premises, care and all five CQC questions; the overall rating remained Good. This explanation was written from the published report of 23 November 2018 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Grasmere Lodge
7 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- June 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2018Goodstayed GoodSafe: GoodWell-led: Good
- December 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2016Requires improvementstayed Requires improvementSafe: InadequateEffective: Requires improvementWell-led: Requires improvement
- October 2015Requires improvementstayed Requires improvementSafe: Inadequate
- August 2015Requires improvementSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- June 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 26 November 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
48 live-in carers within about an hour of Gateshead
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £950 to £1,240 a week. 42 can care for a couple. 10 years' experience on average.
“Petty introduced herself to Mum every time she was caring for her and responded very quickly to Mum if she was distressed in the night.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.