Archived: Glenholme

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

The service was in breach of legal regulation in relation to people’s safe care and treatment and need for consent. People’s care needs were not being monitored and updated to reflect their current needs. Ineffective assessments were conducted to ensure people could consent to their care and treatment.

This service scored 33 (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 did not make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them. We found care plans were inaccurate and did not actively reflect people’s needs. When we spoke to the registered manager they said, “We sit and talk and go through every 3 months. If no relatives, then we do what we can.” There was no evidence of care plans being reviewed as and when people’s needs changed. During our assessment the service re-submitted all care plans to evidence their reviews. Following our review of this information, we identified more concerns. People had specific health conditions that were not risk assessed. However, speaking to staff they had worked in the service for a length of time and knew the people well.

The provider did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them. We found the service did not use any clinical tools to assess peoples care and support needs to ensure they received safe care. o they could not mitigate risk. They would weigh people monthly, but they did not use any tools to assess any risks of malnutrition when they were appropriate to support the needs of people. No assessments were conducted to check the risk of people developing pressure sores. There were no policies in place to reflect required standards. One staff member we spoke with said, “I am not aware of multi universal screening tool (MUST) or Waterlow tools, so cannot comment on national tools used.” However, staff told us if they were concerned about a person, they would carry out some basic observations and told us how they supported a person with a specific dietary requirement.

The provider did not work well across teams and services to support people. They did not share their assessment of people’s needs when moving between different services. They did not make sure there was continuity of care, including when people moved between different services. We spoke to healthcare professionals and identified when people moved to other services these were not always safe, the service failed to provide appropriate care plans and risk assessments to partners to ensure safe continuity of care. Some care plans had hospital passports but we were not assured they were fully reflective of people’s needs. There was no evidence of multidisciplinary meetings occurring on a regular basis. However, one person we spoke with said, “If I need to see the doctor the staff book an appointment for me and take me to it. They tell me about hospital appointments I have, and they arrange them for me. They sort it all.”

The provider did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. Staff did not always support people to live healthier lives, or where possible, reduce their future needs for care and support. We found that care plans recorded that people had gained weight and advised people to choose healthier options and go for more walks. Care plans did not evidence these actions were discussed with a health care professional and they failed to evidence if people knew what healthier options were and if they required support to choose healthier options. They did not offer other alternative ways of exercising. Staff were not trained to support people’s specific health conditions. However, we found people were supported to attend routine appointments and staff told us how some people had voluntary work that they attended and they enjoyed doing it. One person we spoke with said, “Yeah the food is nice, and we get to go out for meals.”

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves. People were not supported to have health actions plans in place. People did not have monitoring charts in place when people were at risk of serious health complications. We found some people who had a history of a bowel obstruction or that suffered with constipation and required regular laxatives were not being appropriately monitored.

The provider did not tell people about their rights around consent or respect these when delivering care and treatment. They did not assess people’s capacity appropriately to ensure they could consent to care and treatment. We spoke to the registered manager they said, “We do mental capacity assessments, and consent forms to care are in place in their care plans.” On review of care plans we found no one had capacity assessments in place when suitable. Throughout our assessment the service began to conduct capacity assessments on people in the service. On review, these were poor and not completed accurately. Decisions people were assessed on were inappropriate and did not meet the principles of the Mental Capacity Act 2005 (MCA). There were no best interest decisions in place when required.