Glencairn Residential 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. At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.
 

The provider was previously in breach of the legal regulations in relation to premises safety and medicines. Improvements were found at this assessment and the provider was no longer in breach of this regulation.

This service scored 75 (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.

There was a system in place to record falls and other incidents and monitor them to ascertain themes or trends that could enable changes that could reduce a reoccurrence. Information from these incidents was shared at both handover and staff meetings so learning could help shape future service provision.

People and relatives felt safe at Glencairn Residential Home, particularly since the registered manager commenced in post. A relative told us, – “Yes, I think they are being kept safe. They were very frail but now have improved. They did have a fall and they [staff] did contact me.” A second relative said, “They have not got capacity and wander at night. They [provider] have put in a safety alert mat in their room which is brilliant and tells them if they get out of bed.”
The registered manager understood their responsibility to monitor and investigate safety incidents and to share findings with relevant others such as GP’s and the local authority.

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.

Pre-admission assessments were completed for all potential new admissions to Glencairn Residential Home. The registered manager and deputy manager met with the person and their representatives if they had any, and information was gathered and assessed as to whether they could be safely supported at the service.
Information about the person, their relatives, friends and health conditions was recorded along with what support they needed with personal care, mobility, nutrition and other areas. Information was also gained on their religious beliefs, interests and social history.
The pre-admission assessments reviewed were fully completed and held sufficient information to complete a basic care plan that would be sufficient for staff to use to provide person-centred support. Over the first few weeks following admission, as more information and needs are learned, plans are developed more fully.
The provider ensured people were supported to attend medical appointments and shared information when they were admitted to hospital to ensure they received proper care.

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.

At our previous inspections we had not been able to fully review how the provider had maintained safeguarding records due to the destruction of said records. At this inspection, though there were few records, there was a clear system to record, share, investigate and review cases. Incidents were reported to the local authority and the Care Quality Commission as required.
Relatives told us, if things went wrong, the provider contacted them. A relative said, “Yes, they are being kept safe. They have had a few falls but they have not been serious ones. They generally ring [name of relative] to tell her about them.”
Applications had been made for Deprivation of Liberties Safeguards (DoLS). DoLS protect the human rights of people who cannot consent to care that restricts their liberty. There was a condition to one authorised DoLS for the provider to review all of the persons mental capacity assessments ‘ASAP.’ This was granted in March 2025 and assessments reviewed in April 2025. They have subsequently been reviewed each month with care file audits.

The provider worked with people 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.

Risks were assessed and measures taken to ensure people were safely cared for at Glencairn Residential Home. Risk assessments were reviewed each month and updated as needed.
At our previous inspection we were concerned no assessment of the risks associated with the use of flammable emollients had been completed. When these are used, people, their clothes and bedding can become flammable. Measures should be taken to reduce these risks. At this inspection, risk assessments had been completed and these risks were mitigated as far as possible.
Relatives believed staff knew their family members well and understood risks. One relative told us, “They may have had a little slip. It can totally happen but [staff] are very quick to pick up on anything. [Staff] have got to know them well. [Staff] call an ambulance if their oxygen levels dip. [Staff] let me know straight away and they always email me to update me about everything. They need constant reassurance as they suffer from anxiety but they have settled in well and feels safe.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The premises were well presented and maintenance was completed in a timely way. The registered manager completed weekly ‘walkarounds’ during which they checked health and safety aspects of the premises. All bar 2 wardrobes had been safely anchored to the wall and all previously identified pieces of furniture were also properly fixed, as were window restrictors. The registered manager was asked to check all furniture on their next ‘walkaround.’ They confirmed all had been checked and were now safely anchored following our inspection.
Two radiators had been identified by the provider as not cool to the touch. These could not be made safe using a radiator cabinet as this would restrict the width of the corridor. The provider was working on a safe solution for this. A relative had noted this, telling us, “It is ok but it is tight moving their wheelchair around the Home due to the narrowness of the architecture.” A staff member told us they thought improvements were needed to the bathroom chair hoist.

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.

Staff supervision could not be evidenced at our last inspection. At this inspection the situation had improved and all staff had participated in 1-to-1 supervision sessions with a line manager. The provider had arranged for supervision, whole team meetings and team meetings to be held every 3 months on a rolling basis. This meant staff were supported well and with daily handover meetings, updates were shared with the team in a timely way.
Relatives were happy with the number of staff deployed. One relative mentioned it would be nice to have more staff but only to make things easier for staff. Another relative told us, “I think there are enough staff around. I see all the same faces and they all seem happy. Whenever I’ve been there are lots on hand anyway. They like to be with people and there are always people around.”
We had conflicting feedback about staff turnover, one relative commenting there were few changes to the staff team while another relative commented on high staff turnover. All feedback was positive about all staff employed by the provider.

Staff completed a wide range of training courses during their induction and updated these at regular intervals. Staff told us they were satisfied with the training they received and could progress to qualification courses to enable progression to more senior roles.

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.

The premises were very clean and throughout our inspection visit, housekeeping staff worked to maintain this. Regular infection prevention and control (IPC) audits were completed and a head of housekeeping ensured actions from these were completed.
The provider had a ‘resident of the day’ process where on the date that matched a room number, that person had all of their records reviewed and a deep clean was also completed of their room. This ensured every one’s room was maintained to a high standard.
 

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Medicines administration had significantly improved and medicines were safely managed. People had protocols to instruct when ‘as and when’ medicines should be offered which were reviewed every 6 months. Homely remedies were available and an overview showed what could be given, how often and when to contact GPs for additional advice.

Since our last assessment visit, robust systems to monitor staff competency, reorder low stock medicines, check controlled medicines and infections had been introduced and embedded into practice. Medicines audits were also regularly completed and identified issues before they became problems. Controlled medicines are subject to high levels of regulation as they have been identified as being especially addictive and harmful.

When medicines errors happened, a detailed incident report was completed and a root cause analysis used to ascertain a possible reason for the error. These were discussed at senior staff meetings which helped reduce the possibility of a reoccurrence.

People were supported to self-administer medicines. A person would receive 2 weeks of medicines at a time which they stored in a locked cabinet in their bedroom. They used a phone alarm to remind them to take their time sensitive medicines.

Relatives confirmed medicines were safely and effectively managed for their family members. They told us people knew what medicines they were taking and staff were very organised when dealing with medicines.