This inspection took place on 6 October 2016 and was unannounced. At our last comprehensive inspection in July 2015 we found the service was in breach of regulations relating to safe care and treatment and good governance and rated it as requires improvement. This was because medicines were not managed safely, risks such as those relating to falls and people developing pressure ulcers were not managed safely and audits were not sufficiently robust. However, when we carried out a follow up inspection to check these areas in December 2015 we found the provider had taken appropriate action and the service was no longer in breach of the regulations. We did not change the rating of the service at that inspection because we wanted to see sustained improvements over time.

Grasmere Rest Home provides accommodation and personal care for up to 23 people, some of whom may be living with dementia. At the time of our visit, there were 20 people using the service. Although the service is required to have a registered manager in post, there was no registered manager at the time of our inspection because this person had recently left the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We found some risks were not managed safely. Cleaning and laundry chemicals were kept where people could access them and potentially come to harm from contact with them. There were insufficient measures in place to manage risks relating to people’s cigarette lighters where they did not have the mental capacity to operate and manage these safely. However, the provider promptly installed a lock on the cupboard where chemicals were kept and the acting manager told us they would review policies around use of smoking materials.

People had personalised risk assessments and these were up to date. Staff knew how to protect people from risks like falls and developing pressure ulcers and there was sufficient equipment in place to manage these risks. Measures were in place to protect people in the event of emergencies and the provider had taken action to help ensure people were protected from the risk of harm and abuse. Medicines were managed safely. Staff were familiar with medicines policies and arrangements were in place to store, administer and record medicines appropriately.

There were enough staff to care for people safely and so that people did not have to wait a long time for help. The provider carried out checks to ensure they did not employ any staff known to be unsuitable. Staff received the training and support they needed to do their jobs. They were able to obtain advice from healthcare professionals about supporting people’s health needs. People had access to healthcare services when needed and were able to choose from a variety of nutritious food and drinks that met their needs.

Staff obtained people’s consent before carrying out care tasks. Where people were unable to consent to their care, staff followed procedures to make sure they worked within the Mental Capacity Act (2005). This included situations where people were deprived of their liberty within the care setting and ensured that the provider was meeting legal requirements in this area.

Staff were caring and showed respect, empathy and compassion in their interactions with people. They regularly checked that people were comfortable and whether they needed anything. They knew people well and took time to listen to them and talk about their experiences. Staff worked with people in a way that promoted their dignity.

People were free to choose how to spend their time and took the lead on deciding what their daily routines should be. People enjoyed trips and outings including a recent canal boat trip and

At our previous inspection in April 2014, we found that people's consent to their care was not always sought before they received care, that legal requirements were not always adhered to where people did not have the capacity to consent and that care was not always planned and delivered in a personalised way. Risks were not adequately assessed and managed and there was not sufficient information about people's end of life wishes to ensure that these were carried out.

At this inspection, we spoke with three people who used the service, two care workers, a representative of the provider organisation and the registered manager of a sister service, who told us they were assisting with the management of Grasmere Rest Home while recruitment of a new manager was taking place. We looked at three people's care plans. We considered our

inspection findings to answer the questions we had asked previously: Is the service safe? Is the service effective? Is the service responsive?

Was the service safe?

Some aspects of the service were not safe. Some risks identified by incidents or assessments had not been assessed and were not being adequately managed as a result.

Was the service effective?

The service was effective. People told us they were asked for their consent before care tasks were completed. They said, "They involve us and discuss our care. We work it out together over a cup of tea.” Another person said, “The manager asked me about my care and got my consent.” Staff were knowledgeable about the Mental Capacity Act and there was evidence that this had been applied appropriately when there were doubts over whether people had the capacity to consent to decisions about their care. People received support from healthcare professionals when they needed it.

Was the service responsive?

The service was not consistently responsive. People had personalised care plans, including information about their end of life wishes. However, the care plans were not always updated to reflect people's changing needs. People told us they received care and support in accordance with their needs and wishes. One person said, "I love it here. [Staff] take care of me. There's always someone here for me when I need them."

When we visited Grasmere Rest Home, there were 18 people using the service. We spoke with three people who used the service and four members of staff. We reviewed five people's care plans and five staff files.

A single inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

Is the service safe?

The premises were safe and well maintained. Staff had training in dealing with emergencies and were aware of how to manage them. Good recruitment procedures were in place to reduce the risks of inappropriate staffing. People's risks were not always individually assessed and some had no management plans in place. In some cases, this meant that there was no formal framework in place to ensure that people were protected against the risks of unsafe or inappropriate care. A compliance action has been set for this and the provider must tell us how they plan to improve.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place and people were free to leave the home as they pleased.

Is the service effective?

Appropriate research and guidance was used to assess people's needs and monitor their health. The service sought input from other services when needed. This included appropriate support with specific medical conditions, nutritional needs and mobility requirements. Staff had received training to support them to meet people's individual needs. People we spoke with felt that their needs were met. One person said, "Whenever I ask for things, I always get them."

Is the service caring?

People told us that staff were polite and respectful and we observed staff responding to people in a compassionate and respectful manner. We did not see evidence that most people were involved in planning their care or that consent had been obtained for their care to be delivered as planned. However, people said their choices were respected. People told us, "The staff are lovely. They are all nice people and they really care" and "Staff are wonderful and they always have time for a joke."

Is the service responsive to people’s needs?

We saw that not everybody who needed a ‘mental capacity assessment’ or a ‘best interests decision’ had these made by the right people. A compliance action has been set for this and the provider must tell us how they plan to improve.

People's needs were assessed before they moved into the home and their care was planned to meet these needs. One person described how the provider had ensured they received the medical treatment they needed. Meals were planned to cater for individual needs and catering staff were aware of dietary requirements. People had enough suitable food and drinks.

Activity plans were tailored to individual preferences and we saw people participating in activities corresponding to the preferred activities in their care plans.

Is the service well-led?

At the time of our visit, there was no registered manager in place. The home's manager told us they had recently submitted an application to become the registered manager. Staff felt able to raise concerns with management and any issues were addressed quickly and effectively. The manager had identified care plans as an area for improvement and demonstrated that they were in the process of making improvements. Staff were involved in making improvements to the service.

People who used the service told us managers were approachable and "you can just knock on the door if you want to give your views."

We spoke with some of the people who use this service and they confirmed that they were happy however, they all had varying degrees of dementia and communication with them was difficult. One person using the service told us ‘I like it here’ and ‘I do not have any complaint.’ Another person said ‘The staff are lovely’.

We were informed that representatives of people using the service were in regular contact with staff at home and they also visited the home on a regular basis.

People were supported in promoting their independence and community involvement. People were given opportunities to express their choices and to make decisions in their daily lives. We observed that staff were aware of people’s preferences and routines so they could support people in their daily lives. For example they knew at what time people preferred to eat and what time they went to bed or got up. From our own observations we saw staff treated people using the service with dignity and respect.

We spoke with some of the people who use this service and they confirmed that they were happy however, they all had varying degrees of dementia and communication with them was difficult. The views of people who were able to comment on their experience can be summarised as follows "the staff are very kind and helpful" and "they are kind to me". All the people we met appeared to be happy and looked well cared for.

Overall, people we met told us that staff always treated them well and listened to what they had to say. Comments included, ‘they look after me well ’, ‘the staff are good’ and ‘I like living here’. We also spoke with a relative that was visiting who told us that the care in the home was very good and any issues that arose would be addressed promptly.

This inspection took place on 19 January 2016 and was unannounced. At our last focused inspection on 19 October 2015 we found the provider was not meeting legal requirements in relation to safe care and treatment and good governance. We served the provider a warning notice in relation to the breach of regulation in relation to good governance and served a requirement notice for the breach of regulation related to the safe care and treatment of people. After the inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches.

We undertook this focused inspection to check the provider had followed their action plan and to confirm that they now met legal requirements and had addressed the areas where improvements were required. We found the provider had taken all the necessary action to improve which meant they were no longer in breach of regulations.

This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Grasmere Rest Home on our website at www.cqc.org.uk

Grasmere provides accommodation for up to 25 older people some of whom were living with dementia. During our inspection there were 19 people using the service.

There was no registered manager in post although the manager who had started in March 2015 was in the process of registering with CQC. A registered manager is a person who has registered with CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The provider had made improvements to medicines management systems which meant they had taken action to protect people against the risks associated with medicines. Our stock checks indicated people received medicines as prescribed and that records the provider made regarding medicines were accurate. The provider had introduced effective medicines audits so they regularly checked that people received their medicines as prescribed.

The provider had reviewed the tool they used to assess people’s risk of developing pressure ulcers. However the provider did not always assess people’s risk of developing pressure ulcers monthly when required. This meant they may not be using the tool appropriately to check people received the right support. The provider put in place the right support people needed when they identified they were at risk of developing pressure ulcers.

People received the right support in relation to falls. The provider referred people promptly to the falls prevention team, a specialist NHS service, and followed the advice provided.

The provider carried out a range of audits including regular checks of care plans and risk assessments, records maintained about falls and training, DoLS authorisations, medicines and other aspects of the service. The director told us they would create a deputy manager role to support the manager to oversee the service and review care records as necessary. Appropriate health and safety checks were in place and the provider was on schedule with regards to their action plan to reduce the risks of Legionella in accordance with their Legionella risk assessment. These audits were effective in identifying and rectifying issues as part of improving the quality of service provided to people.