12 January 2023
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.
As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
The inspection was completed by 2 inspectors and an Expert by Experience who made calls to people and their relatives. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
Glenfields Care Home Limited is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Glenfields Care Home Limited is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.
At the time of our inspection there was not a registered manager in post. A new manager was in place at the time of the inspection and had started the process to register.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We looked at information sent to us since the last inspection, such as notifications about accidents and safeguarding alerts. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We contacted the local authority safeguarding and contract teams and Healthwatch for feedback. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used all this information to plan our inspection.
During the inspection
We spoke with 8 members of staff including care staff, senior staff, the manager and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We also spoke with 4 people who used the service, 6 relatives and observed staff interactions.
We looked around the home to review the facilities available for people and the infection prevention and control procedures in place. We also looked at a range of documentation including care files, daily records and medication administration records for 4 people. We looked at 3 staff recruitment files and reviewed documentation relating to the management and running of the service such as staff rotas, training and audits.
12 January 2023
About the service
Glenfields Care Home Limited is a residential care home providing personal care to up to 28 people who may be living with dementia, physical disabilities or sensory impairments. At the time of the inspection, 25 people were using the service.
People’s experience of using this service and what we found
Quality assurance systems had not identified and addressed shortfalls which were found during the inspection which included issues with medicines and records including risk assessments, fire and recruitment. People’s medicines were administered safely and staff were knowledgeable about when people needed their medicines, although there was a lack of guidance in place for staff. We have made a recommendation about medicines processes. The manager and provider started working to address the shortfalls we found.
People were supported by trained staff with the skills and knowledge to meet people’s needs safely and in a timely manner. Recruitment processes helped ensure staff were suitable to work with people, although recording and organisation systems needed reviewing. The manager monitored staffing levels which were safe. We received mixed feedback about staffing levels. However, people and their relatives were positive about staff and the care they provided.
Although shortfalls were found in the regular reviewing of risk assessments and fire records, staff effectively managed risks to people’s safety and wellbeing. People were protected from abuse, one relative said, “The best thing about this service is that it is clean, friendly with no fear my relative is suffering any abuse.”
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; the policies and systems in the service supported this practice.
There was a caring, positive culture at the service and most people, and their relatives were happy with the service provided. Systems were in place to gather feedback from people, their relatives and staff to develop the service. Staff were supported by the provider and the manager and were positive about the changes made since the manager had been in post.
For more details, please see the full report which is on the Care Quality Commission (CQC) website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was requires improvement (published 2 July 2021). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulation.
At our last inspection we recommended the provider ensured staff received appropriate training to record all reviews and monitoring of risks and take action to update their practice accordingly. At this inspection we found some improvements had been made.
The service remains rated requires improvement. This service has been rated requires improvement for the last 2 consecutive inspections.
Why we inspected
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.
We received concerns in relation to care provided, cleanliness, staffing levels and records. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
The overall rating for the service has not changed and remains requires improvement based on the findings of this inspection. We have found evidence that the provider needs to make improvements. Please see the well-led sections of this full report. You can see what action we have asked the provider to take at the end of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Glenfields Care Home Limited on our website at www.cqc.org.uk.
We have identified a breach in relation to the quality assurance systems at this inspection. Please see the action we have told the provider to take at the end of this report.
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.