Glebe Villa

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 changed to good. This meant people were safe and protected from avoidable harm.

The service was previously in breach of regulations relating to the safe recruitment of staff and training. Improvements had been made, and the service was no longer in breach.

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.

Systems were in place to capture incidents, accidents and complaints. This included what the concerns were, what action had been taken to minimise further risks and any learning.

Lessons were learnt to continually identify and embed good practice. For example, the registered manager held regular meetings, where staff could share safety concerns and good practice. A member of staff told us, “If we have any concerns they are addressed quickly.” A further member of staff told us, “They always listen to us especially when we have important concerns.”

There was evidence of openness and transparency, in line with duty of candour requirements. Relatives confirmed they were kept informed of any incidents, accidents or safeguarding concerns.

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.

Two new people had recently moved to Glebe Villa. A comprehensive assessment was completed seeking the views of the person, their relative and health and social care professionals. The registered manager told us they had visited people in their previous health settings enabling them to get to know them. People were supported to visit Glebe Villa as part of the assessment process to enable them to make a decision on whether they wanted to move permanently to the home.

From these assessments it was noted that two people had a clear diagnosis of mental health and were supported by local mental health services. Whilst it was evident they were meeting the needs of the people and staff had received training in mental health, the service did not have the service user band mental health. We have recommended the service adds this to their registration.

Healthcare passports were in place to support people when they were admitted to hospital or move from one service to another to ensure continuity of care. This contained important information enabling health professionals to get to know people. This supported them to make adjustments as needed, such as how a person communicated and the support they needed to make decisions. These also included a summary of healthcare appointments to give health care professionals an oversight of others involved in the care of the person.

People told us they were supported to attend healthcare appointments, and other professionals were involved in their care as necessary. Specialists such as the local community learning disability team, mental health services, neurology and speech and language professionals supported people who lived at Glebe Villa. Clear records were completed of any appointments including any follow up appointments or actions that needed to be completed.

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 provider had appropriately raised safeguarding concerns. This included sharing information with the local authority and the Care Quality Commission (CQC). The level of information shared with other agencies had been appropriate and sufficient to keep people safe. As a result of the safeguarding concerns and subsequent investigations, changes were made to people's care arrangements when required to keep them safe and help prevent recurrence.

Staff confirmed they knew what to do in the event of an allegation of abuse being made. All staff completed safeguarding training. Staff were aware of the reporting process for allegations of abuse. There were policies and procedures to guide the staff on what to do if an allegation of abuse was made and how staff could raise concerns using the whistle blowing policy.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). In care homes, this is usually the Deprivation of Liberty Safeguards (DoLS). We found the service was working within the principles of the MCA. Deprivations of Liberty Safeguards were in place where people lacked mental capacity. Where people had specific conditions these had been completed and clearly recorded in the person’s care plan.

The registered manager told us that there were no longer using restraint with one person as noted at the last inspection. They told us, “Staff were following the person’s positive behaviour support plan, and the individual was more settled.” This was observed during our visits to the home. Staff had completed training in positive behaviour support. This was updated annually by the area manager who was a train the trainer in this topic area.

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.

Risk assessments were in place to help keep people safe whilst they were in their home and the community. This included planning for holidays for people ensuring staff had guidance available to minimise risks whilst away from the home. Where people were at risk of malnutrition and weight loss, systems had been put in place to monitor these areas including skin integrity.

Staff described how they kept people safe without restricting them and supported them to have control over their life. Environmental risk assessments had been completed to help keep people and staff safe.

The registered provider responded to feedback given during the assessment that one person’s risk assessment did not capture the staff support they needed when out in the community or with personal care. It was evident that staff were aware that the person needed 2 staff when leaving the home unless within the immediate area and described to us how personal was delivered safely.

No harm had come to the person, and an updated risk assessment was shared with us during the assessment that fully captured the support that should be in place. The registered manager told us all risk assessments were continually reviewed to ensure they were not restricting people and promoted their independence.

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

There was a programme of ongoing maintenance, refurbishment and decoration. There had been extensive building work completed since the last assessment. This included moving the office and the laundry to an external building, which enabled the lounge area to be extended. Medicines were no longer stored in the lounge area as these had moved to small side room off the lounge. These changes had been positive, and people told us they had more room to relax in their lounge.

One person’s bedroom had been identified to be redecorated in December 2025 and the provider confirmed this was planned over the next few weeks. It was noted this person needed support to maintain their environment. The staff had been proactive in seeking support from an occupational therapist to help the person understand the importance of keeping their bedroom tidy and free from clutter due to the risks of falls and other hazards.

Systems were in place to ensure the home was safe. This included checks on equipment, fire and gas appliances. Emergency plans were in place to ensure people could be kept safe in the event they had to evacuate the home. Adaptations such as key codes on doors, restrictors on windows and covers on radiators all helped to keep people safe.

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.

The provider had made improvements since the last assessment and had demonstrated compliance with the legislation. The provider safely recruited staff, and relevant checks were carried out before staff started work at the service. This included criminal record and employment checks to confirm staff were suitable to care for people.

The registered manager told us they had sufficient staff to support the people they were supporting. There were no staff vacancies at the time of the assessment. Staff confirmed there was sufficient staff working in the home at all times to support people to do the things they wanted to do. Staffing had been increased since the last assessment as one person needed increased support when in the home and the local community. Staff confirmed that if they fell below four staff during the day either the deputy manager or the registered manager would support.

People were supported by staff who had an induction that included shadowing more experienced staff, ongoing training and formal competency checks. Staff that were new to care completed the care certificate as part of their induction. The registered manager and the provider monitored ongoing compliance to training.

Improvements were seen at this assessment in relation to training for staff. All staff had attended training in supporting people who may become distressed. A member of staff told us, “We have lots of training, including supporting people with mental health and learning disabilities.” The trainer told us “Staff attend the training, but we also check their knowledge and competence. The training is person centred and reflects the people we support rather than being generic.”

There was a training programme in place, which was monitored by the registered manager and the provider’s representative. All staff had to complete refresher training at regular intervals. Examples included health and safety, first aid, safeguarding, equality and diversity, safe medicines administration, food hygiene, moving and handling, deprivation of liberty safeguards and mental capacity.

Staff received regular supervision and yearly appraisals.Spot checks had been introduced since our last assessment to ensure staff were competent and to help identify any gaps in learning.

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. We found the home to be clean and free from odours. People and their relatives felt the home was clean and tidy and no concerns were raised. A cleaning rota was in place to ensure the home was cleaned either daily, weekly, fortnightly or monthly. People were supported to help to clean their bedrooms.

Staff had completed infection prevention and control training. Spot checks were completed to ensure staff were following the policies and procedures and not putting people at risk. Staff said they had enough personal protective equipment (PPE) such as gloves and aprons. Infection prevention and control policies were in place.

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.

People were given medicines in line with their wishes. Each person had individualised medicine support plan and risk assessments. Medicine administration records were clear and showed people were receiving their medicines as prescribed by the GP.

People's medicines were stored securely, and clear and accurate records were maintained when they were given. Monthly audits were completed to ensure people received their medicines safely and to identify any gaps and make improvements.

The GP had been consulted on homely remedies to ensure they were appropriate and no contra-indications for people’s regular medicines. Where a person required their medicines to be given covertly (without their awareness) this was clearly recorded and with the agreement and involvement of the person’s GP and healthcare professionals.

The service ensured people’s behaviour was not controlled by excessive and inappropriate use of medicines. Staff understood and implemented the principles of STOMP (stopping over-medication of people with a learning disability, autism or both) and ensured that people’s medicines were reviewed by prescribers in line with these principles. A healthcare professional confirmed people medications were continually reviewed. The registered manager told us a pharmacist had recently reviewed everyone’s medicines and the systems in place to ensure these were safe.

Staff received annual medicine training, and their competencies were assessed to ensure medicines were managed safely.