The Glow Rest Home

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• 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. At our last assessment we rated this key question good. At this assessment the rating has changed to 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.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People did not always receive consistently safe care as the provider did not have a proactive and positive culture of learning lessons.

The services registered manager had not taken appropriate action to address issues we identified at their previous assessment in relation to their governance systems which remained ineffective. They had also failed to identify or address some new issues we found at this assessment in relation to their fire safety arrangement and the training and formal support staff received. The registered manager told us they were aware they needed to develop a more effective and proactive approach to monitoring and continuously improving quality and safety within the care home.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The registered manager had gathered information about the persons individual needs and wishes, prior to them moving into the care home. This information was used to develop a person-centred care and risk management plans which the manager [registered] and staff followed. The registered manager and staff worked closely with all the relevant family members where applicable and external health and social care professionals and bodies to ensure the persons care plans remained up to date and reflected their current needs and wishes.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

The person told us, “I feel safe living here.” The registered manager and staff understood how to safeguard them. They knew how to recognise and report abuse and were able to articulate how they would spot signs if the person was at risk of abuse or harm. A staff member said, “I would inform the manager [registered] if I saw anything bad happen here. If it involved the manager [registered] I know I must tell the local authorities safeguarding team and the CQC.”

The service was working within the principles of the Mental Capacity Act 2005 (MCA). The registered manager and staff understood persons capacity to make decisions about their care and support using people’s preferred method of communication.

The service worked with the person to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff were knowledgeable about the risks faced by the person they cared for and managed them well. Staff were aware how to respond if the health of the person they supported declined, they would help them access the relevant healthcare services. Staff were attentive and alert to any changes that might indicate the person needed additional support.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment and facilities supported the delivery of safe care.

Contrary to the providers own fire safety policies and procedures and recognised best fire safety practice, the providers fire safety arrangements were ineffective. The registered manager was unable to provide us with any recorded evidence to assure us fire safety checks were being routinely conducted within the care home. No fire safety risk assessment of the premises had not been completed, a personal emergency evacuation plan was not in place for the person living in the home, fire evacuation drills involving staff had not been undertaken or recorded at regular intervals, and the providers fire alarm system was not being tested weekly. This meant the provider had not done all that was reasonably practicable to mitigate potential risks associated with the care homes environment which had placed people at unnecessary risk of harm.

The person told us the care home was a comfortable place to live. The environment was free from unnecessary slip or trip hazards which enabled the person living there to move safely around with support from staff.

The service did not always make sure staff received effective support, supervision and development. They did ensure they were enough experienced staff who worked well together to provide safe care that met the individual needs of the person they supported.

Staff had not received any formal supervision meetings or had their overall work performance appraised in the last 12 months, contrary to the providers own staff supervision and appraisal policies and recognised best staff support practice. Staff told us they did not have any formal recorded meetings or work performance appraisals with the registered manager, but they were in daily contact with each other as they all lived together in the one home. This meant staff did not have enough formal opportunities to reflect on their working practices and professional development.

Staff had received most of the relevant training they needed to meet the needs of the person they supported and the registered manager and staff told us an external trainer routinely refreshed their training annually. A staff member said, “Every year a gentlemen comes to the house to refresh all our training.” However, staff’s training certificates indicated their training had not been refreshed for many years.

The provider employed enough experienced staff. A staff member told us, “There’s always at least 2 members of staff at home and most of the time there will be 3 of us.” On arrival at the care home the registered manager and 1 member of staff were both on duty. The registered manager confirmed the 2 care staff she employed both lived in the care home along with herself. This ensured the person they supported received continuity of care from this same small group of staff who were familiar with their individual needs, preferences and daily routines.

The provider operated safe recruitment practices and only suitable staff were employed to live and work in the care home.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. People were supported to live in a clean, hygienic environment.

Staff had access to resources and equipment to help them reduce infection risks and used this appropriately, which included adequate supplies of personal protective equipment [PPE].

The service did make sure medicines met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff had received safe management of medicines training. Staff had clear documents that they used to record medicines administration. These were regularly reviewed by the GP and pharmacy. The persons care plan included detailed guidance for staff about how they needed and preferred their medicines to be administered.