Glenroyd

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 requires improvement. At this assessment the rating has remained 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 59 (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.

The registered manager was passionate about continual improvement and innovation. Staff felt they were involved and engaged with the improvements the registered manager had introduced and all staff we spoke with told us the service had changed for the better.

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.

There was a joined-up approach to working with health care staff. The GP visited each week and in advanced of this, staff would identify people who would benefit from a GP review. Staff knew people well and were confident in handing over information to visiting professionals. Leaders worked with health and social care organisations, such as hospitals and the Local Authority, to support people to be admitted to the service in a timely way.

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.

Safeguarding systems were in place and incidents were appropriately reported to the Local Authority and CQC. Staff understood safeguarding responsibilities and discussed these during their supervision. People using the service and their families expressed feeling safe, with 1 relative stating, “[Person] feels safe here, they are content in their room.”

The provider did not always work with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. We found for some people, who were at risk of pressure ulcers, were not always repositioned within the agreed time to ensure their skin remained intact. While we found people were unharmed due to these delays, it significantly increases the risk of skin damage. However, people were involved in managing risks through personalised care planning and regular reviews. Risk assessments were tailored to individual needs, including choking, falls, and pressure ulcers. Staff used nationally recognised tools to assess wellbeing. However, families were consulted and informed about changes, and staff used “All About Me” cards to engage with people meaningfully. A family member shared, “They always let us know if there is anything like appointments.”

The environment was generally safe and well-maintained. Bedrooms were personalised and clean, and call bells were accessible. Some areas were not clean on the first day of our two-day site visit. Additionally, doors that should have been locked were left unlocked, but these issues were resolved promptly. Whilst maintenance staff worked hard and flexibly to maintain the service, some parts of the service needed renovation. Environmental documentation had gaps, particularly in water temperature and window restrictor checks, which were resolved by the end of the inspection. Fire safety systems were in place, with evidence of servicing and drills, although the fire risk assessment review was overdue, this was resolved during the inspection.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked well together to provide safe care that met people’s individual needs.

Staffing levels had improved since our last inspection. There was increased night staffing and reduced agency use. Staff felt supported and valued, and recruitment processes were safe. One staff member said, “There are enough staff. It has gotten much better.”

The provider did not always assess and manage the risk of infection. While they largely detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly, this was not always consistent.

Infection prevention and control practices were largely effective but did not manage all areas of infection. Staff followed hand hygiene protocols and used personal protective equipment (PPE) appropriately. Clinical rooms were clean and well-organised. Observations showed good practices during medication rounds. A staff member noted, “We use hand gel and follow good practices.” We did find some chipped paintwork, rusted bathroom aids and stained and heavily worn carpets. Some renovations had been approved by the provider following the inspection which will complete in the coming months.The Registered Manager attends all provider forums with the Local Authority’s adult social care infection prevention and control meetings.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. While medicines were generally administered safely, with correct labelling and protocol, we found gaps in medicine charts and stock control, so we could not be assured people had received their prescribed medicines. However, staff were knowledgeable and had received training, but inconsistencies in recording and equipment use impacted safe practice however there was no evidence anyone had come to harm.