Glynn Court 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 changed to 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.

The service was in breach of legal regulation in relation to safe care and treatment, staffing and premises and equipment.

This service scored 53 (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.

Lessons were learnt to identify and embed good practice. Staff knew what incidents to report and how to report them. The registered manager shared learning with staff through team meetings, supervision and staff communication channels.

The registered manager told us they received safety alerts from the government, local authority and CQC which informed them of upcoming risks along with themes and trends to ensure they could take appropriate action to mitigate these risks. They shared this information with staff.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They tried to make sure there was continuity of care, including when people moved between different services.

The provider had a robust admissions policy in place. The registered manager described how they assessed people to establish suitability and compatibility prior to moving in. They told us, “We involve people and those involved in their care.”

Staff knew people well and shared information with ambulance crews and hospital staff when required to ensure continuity of 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 free from bullying, harassment, abuse and discrimination. The provider shared concerns quickly and appropriately.

People told us they felt safe living in the home and staff knew how to protect people from abuse and who they would report any concerns to both internally and externally. The registered manager shared concerns appropriately by following the correct reporting process and informing all relevant agencies.

Some people had restrictions placed on them and required supervision to ensure their safety. Where required, there were legal authorisations for people under the Deprivation of Liberty Safeguards (DoLS) to keep them safe.

The provider did not always work well 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 staff knew people well and we did not identify any concerns with staff practice. However, risk assessments were not always updated when people’s needs changed and lacked detail. For example, a person had a moving and handling assessment which was not updated when the person’s needs changed. The registered manager told us another person required a soft diet due to swallowing difficulties. Their diet and fluids risk assessment referred to offering choice when eating but failed to mention this person needed a modified diet. We spoke with the registered manager about this who started making changes to the risk assessments during the inspection.

We observed walking frames being stored in the lounge away from people. This meant people had to request them to use them. There was a risk people would try to mobilise without access to their walking frame, placing them at risk of harm.The provider told us they did this based on individual risk assessments. However, there were no risk assessments in place for staff to follow. People who lacked capacity did not have mental capacity assessments or best interest decisions in place for the removal of their walking frames. The registered manager told us they would complete risk assessments and mental capacity assessments to cover this.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

We observed equipment being stored in corridors including hoists, wheelchairs and bed rails. This posed a trip hazard.

There was a boiling water dispenser in the small kitchen. A note on the door stated it should be always locked when no staff were there. We found this door left open on the first site visit, putting people at risk of harm. This door was locked on our second site visit.

During the inspection, we saw a bedroom containing multiple electrical cables and devices connected to power outlets. Items were placed on top of plugs and extension leads, and electrical devices were charging on top of objects and clothing, which increased the risk of fire. We spoke with the registered manager about this who took action to make this safe.

Weekly fire alarm testing records were not consistently completed weekly. In a 24-week period, fire alarms had been tested on 8 occasions. This meant faults may have been missed, which placed people at risk of harm. Following the inspection the registered manager told us they had put a new system in place and fire alarm testing was now taking place weekly.

The provider did not make sure there were enough qualified, skilled and experienced staff.

Staff voiced their frustration about being unable to provide unhurried, individualised care to people because staffing levels did not allow them to spend time with individuals. Staffing levels had reduced, and of the day staff on duty, 1 solely undertook kitchen duties and another oversaw and administered medicines. On occasion, staff had to undertake cleaning and laundry duties as well as providing care. Staff were busy throughout our site visits, although their communication with people was always calm. The registered manager informed us the provider had introduced these staffing changes to mirror how the provider’s related companies arranged their staffing in their homes in another area.Following the inspection the provider told us they have actively supported recruitment, including sponsoring staff through overseas recruitment to help stabilise staffing levels. They told us staffing levels are determined based on individual needs of people.

Pre-employment checks had not always been completed when recruiting staff. Staff recruitment records did not contain a full employment history. Where there was a partial recruitment history, gaps in employment had not all been explored. This increased the risk that staff unsuited to care work, would be employed in the service.

Staff supervision took place and staff received training and competency assessments to support them in their role.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The service was found to be mostly clean. However, we found the larder floor required cleaning. The laundry had a floor which was difficult to clean. The providers IPC audit dated 28 May 2025 identified ‘The flooring in the laundry needs to be cleaned and re-painted.’ This work was still outstanding at the time of the inspection.

The provider identified in their IPC audit on 28 May 2025 that there was no wash hand basin in the laundry for staff to use. We also observed a toilet in the service, which people used, without an associated hand wash basin. Immediate, accessible hand washing reduces the risk of cross-contamination. The lack of hand-washing facilities in these areas increased the risk of harm to people. Staff had attended 3 yearly infection control training and were observed to be wearing appropriate PPE where required throughout the inspection.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

Medication administration records did not show the time people received their medicines which meant staff could not determine if minimum gaps required between doses had been observed. This placed people at risk of harm.

‘As required’ medicines protocols did not always describe the minimal interval required between doses. Not all ‘as required’ medicines had an ‘as required’ medicines protocol in place to guide staff how to administer them safely. The registered manager told us, if they had given a person’s regular paracetamol later in the morning they would miss their lunch time dose. This meant people were not always receiving all their pain medicines. We spoke with the manager about our concerns; they told us told us they would put a system in place to mitigate the risks going forward.

Some medicines were prescribed in variable doses. There was not always clear guidance to describe when 1 dose should be administered and when 2 doses should be administered. The registered manager told us they would seek guidance from the GP and amend the guidance for staff. Where people were prescribed flammable creams risk assessments did not contain sufficient detail to ensure the people were supported to safely manage this.

One person was prescribed medicines to be given covertly. Most of the medicines had been approved by the GP. However, there was 1 medicine which was being given covertly which was not on the GP’s letter of approval.

Creams were found to be left in people’s rooms on their sinks. There were no risk assessments in place to determine if this was safe practice.

Controlled drugs were managed, stored and returned safely.