All inspections: Glencairn Residential Home

Date of assessment: 11 December 2025
Glencairn Residential Home provides accommodation and personal care up to 23 people over 65 years of age who may be living with dementia or physical disabilities. When we assessed the service there were 20 people using the service.

We assessed the service to review warning notices issued in January 2024. We had previously reviewed the warning notices in June 2024 and at that time not enough improvements had been made. The provider was previously in breach of the legal regulations in relation to premises safety, medicines and good governance. Improvements were found at this assessment and the provider was no longer in breach of these regulations.

Significant improvements had been made since our last assessment. Where records had been missing at previous inspections, there were now numerous records which showed systems such as reviewing incident reports to monitor for themes and patterns were embedded into regular practice at the service.

Sufficient staff were deployed to provide support to people. We saw staff taking time to speak with people and spend quality time with them as well as completing care tasks.

The premises were very clean, we noted no malodours and the provider had reintroduced deep cleans on a monthly basis which ensured each bedroom was maintained at a high standard of cleanliness.

Medicines administration was safely managed. Previous concerns had all been addressed and the improvements were embedded into practice.

Care plans were reviewed each month and people and relatives were asked their views and received updates. Care was provided in line with current evidence based good practice and standards.

The management team consisted of a newly registered manager, supported by a deputy manager and the nominated individual who was also the service owner. They worked within a clear structure and embodied the culture and values they had developed in the service.

We identified some gaps in Mental Capacity Act assessments which we discussed with the management team. These were addressed following initial inspection feedback.

At this inspection we found evidence to support an overall rating of Good.

Glencairn Residential Home provides accommodation and personal care to up to 23 people over 65 years of age who may be living with dementia or physical disabilities. When we assessed, there were 21 people using the service.

We conducted a site visit of the service on 18 June 2024 to review a warning notice issued in January 2024, and assess the Safe key question. We spoke with people, staff and leaders and reviewed records.

At our assessment in January, we found most records were not available. At this assessment, we found records in place that assured us processes to assess and monitor safety within the service were in place.

In January 2024 we found significant concerns in medicines management, storage and administration. We also had concerns the service was not following best practice guidance and not referring people for relevant healthcare assessments. At this assessment, referrals had been made to appropriate healthcare professionals and best practice guidance followed.

There have been significant improvements in medicines optimisation, storage has been vastly improved with the development of a medicine’s storage room complete with new cabinets and air conditioning to ensure a regulated temperature. However, there were still areas of medicines processes that needed to be improved and they remain in breach of Regulation. Areas for improvement include record keeping, medicines audits and management of open stock.

We saw regular premises safety records had ceased when the maintenance person left. This was a breach of Regulations.

The provider has engaged fully with the Care Quality Commission and local authority quality improvement teams and shared service improvement plans and developments with both regularly.

We have asked the provider to submit action plans for the areas that remain in breach of Regulations.

Glencairn Residential Home provides accommodation and personal care to up to 23 people who were over 65 years of age and may be living with dementia or physical disabilities. At the time of our assessment there were 23 people using the service.

We conducted a site visit of the service on 20 and 22 February 2024. We spoke with people, staff and leaders and reviewed records.

We found most records were no longer available at the service, this was noted prior to the acting manager commencing in post. There was little evidence to assure us of the safety and effectiveness of the service.

We found significant concerns in medicines management, storage and administration. We also had concerns the service was not following best practice guidance and not referring people with swallowing difficulties for a relevant assessment and those with unplanned weight loss had not always been seen by their GP.

These concerns along with a lack of risk assessments in care records and poor staff support are a breach of the safe care and treatment regulation.

We were not assured there was good oversight of the service. Prior to the acting manager, there was no evidence of completed audits, safeguarding records, or accurate, complete and contemporaneous records detailing peoples care needs and delivery. This indicated a breach of regulations concerning good governance.

In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and / or appeals have been concluded. We have also asked the provider for an action plan in response to our concerns.

About the service

Glencairn Residential Home is a residential care home providing accommodation for persons who require personal care to up to 23 people. The service provides support to older people. At the time of our inspection there were 19 people using the service.

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

People and relatives told us Glencairn Residential Home was safe, staff knew them well and they were well cared for. One person said, “It’s very nice here, the staff are very nice, kind and I have a good relationship with them. I feel safe living here, this is my home.”

Safeguarding referrals had not always been made appropriately to the local authority. We have made a recommendation about using local safeguarding procedures when necessary. Reportable incidents had not always been reported to CQC. We have made a recommendation about the provider and registered manager’s legal requirements.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; however, the policies and systems in the service did not support this practice. Mental capacity and best interest decision paperwork had not always been completed to show the least restrictive decision had been made for people who lacked capacity. We have made a recommendation about the policies and systems at Glencairn Residential Home to support people who lack capacity.

Staff knew how to recognise signs and symptoms of abuse and who to report their concerns to. Risks to people’s health, safety and well being had been assessed and were regularly updated to keep people safe. People received their medicines as prescribed by staff who had been trained to administer medicines safely.

The home was clean and tidy, staff had received training on how to keep people safe from the spread of infections. Staff had access to personal protective equipment (PPE) and wore this appropriately.

There were enough staff to meet people’s care needs and staff had been recruited safely into the service. Throughout the inspection we saw kind, relaxed, compassionate and caring interactions between people and staff. We observed staff were respectful of people and took time to offer support and reassurance when needed. Staff received training, support and supervision. Staff told us they felt well supported to carry out their roles and told us everyone worked very well together as a team for the benefit of the people living at Glencairn Residential Home.

People had access to nutritious, home cooked food that they enjoyed and were given choice in their menu selections.

Care plans were person centred and detailed how people wished and needed to be cared for. People and relatives felt included in the planning of care and knew who to complain to if they needed to do so.

People, relatives and staff were complimentary about the registered manager and provider. One person said, “I would recommend anyone to come and live here, the [registered manager] and [provider] speak to me most days, they are nice, kind and caring.” There were governance arrangements in place and systems to monitor the quality and safety of the service provided. Where shortfalls had been found during the inspection, the registered manager and provider took immediate action to address this.

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

Rating at last inspection

This service was registered with us on 2 February 2022, and this is the first inspection. The last rating for the service under the previous provider was Good, published on 11 March 2021.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Glencairn Residential Home

All Inspections

During an assessment under our new approach

During an assessment under our new approach

During an assessment under our new approach

24 May 2023

During a routine inspection