Glebe House Retirement 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.

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.

Safety incidents were investigated and reported. Staff knew how to record incidents or accidents, and how to escalate safety concerns. The registered manager reviewed and investigated these and made sure appropriate action was taken in response. The quality of investigation reports could be improved to demonstrate how conclusions had been reached. Any learning from their investigations with staff to help them improve their working practices and keep people safe.

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.

Where people required support from other professionals, such as occupational therapist or dietician referrals were completed promptly and advice was sought and included in peoples care plans.

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 service shared concerns quickly and appropriately.

People were protected from abuse because staff were trained and confident in raising concerns. Staff described safeguarding processes clearly, and records showed concerns were reported to the local authority and CQC where appropriate. A member of care staff told us, “I would report it [safeguarding] to the senior or manager and follow safeguarding procedures and ensure the resident is safe.” People and their relatives told us they had no concerns about safety at the service. A person living in the service told us, “I feel safe.” A relative said, “We have complete confidence that [relative] is kept safe.”

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found the provider had systems in place which ensured they worked within the principles of the MCA and where needed applications had been made for DoLS to the authorising body. A system was in place to monitor the application of DoLS to ensure updates were requested as required.

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.

Care plans contained risk assessments. However, these did not always effectively assess the identified risk and demonstrate how the risk was mitigated. For example, a person had been identified as at high risk of pressure ulcers due to multiple contributing factors. The care plan did not show how the risk was mitigated, for example by using pressure reliving equipment. Another person had been identified as at risk of a poor fluid intake. Their fluid intake was being recorded but the care plan did not record what their target fluid intake should be. Lack of this detail may mean staff were not aware how risks were managed and what action should be taken to manage the risk.

On one occasion during our first inspection visit we observed staff use inappropriate moving and handling techniques which put a person at risk of injury. We fed this back to the management team. On our second visit we found action had been taken to ensure staff did not use that technique again.

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.

During our first inspection visit we found several concerns with the safety of the environment. These included uncovered hot pipes, trip hazards, torn and worn upholstery on furniture and unsafe window closure systems.

The provider had an improvement plan in place but audits supporting the improvement plan had not identified the concerns found at the inspection. For example, the housekeeping quality audit dated 2 February 2026 asked the question ‘Are the baths, seats and bath panels free from dirt and scale?’ This had been ticked as compliant. However, the audit had not identified that some bath panels were broken and insecure presenting an injury risk to people when using the bath.

We fed back the concerns found at the end of our first visit.

On our second visit we found that several of the concerns had been addressed, this included making the window closures safe and covering exposed pipes. There were also plans in place to identify and address shortfalls in the longer term.

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.

People told us there were enough staff to meet their needs. A relative said, “I am confident there are sufficient staff.” A member of care staff said, “Generally staffing levels are good and allow us to provide safe and effective care.”

Staff told us they received appropriate support and training for their role. A member of care staff said, “We have online training, various courses and also have people come in to do training.” Another member of staff said, “I feel well supported through regular supervisions, one to one meetings and team discussions.”

The registered manager used a dependency assessment tool to assess how many staff were required to meet people’s needs.

There were safe recruitment practices at the service. The provider carried out the necessary checks required on staff that applied to work at the service, to make sure they were suitable to support people.

The provider did not always assess or manage the risk of infection.

During our first inspection visit we observed practices which raised concerns regarding infection control procedures. These included uncovered toilet brushes and used personal protective equipment (PPE) disposed of in uncovered waste bins. We also identified areas which did not support effective infection control. These included rust on some equipment, stained flooring and a plastic urine bottle left on the side of a bath. These could all provide an environment for infection to multiply. These were fed back to the management team at the end of the visit.

During our second inspection visit we found some improvements had been made. These included the removal of rusty equipment. The registered manager was also looking to make a member of staff an infection control champion to support staff to maintain effective infection control procedures through the sharing of best practice.

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

People were supported to take their medicines when they needed these. Medicines stock and records confirmed people received the medicines prescribed to them. Senior staff undertook monthly audits and regularly assessed the competency of staff to check they were administering medicines safely.

Guidance in place to support staff in the administration of ‘as required’ (PRN) medicines did not consistently include information about how people might communicate or behaviours they may display when they required these medicines. This presented a risk that staff may not be able to recognise non-verbal indicators fort PRN medicine such as pain relief and to support people accordingly.

Information in the medicines administration record regarding one person’s medicines needing to be crushed was out of date. They no longer required their medicines to be crushed as they now received them in liquid form.