Archived: Glenholme

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant services were not planned or delivered in ways that met people’s needs.

The service was in breach of legal regulation in relation to person centred care, care plans did not reflective peoples’ current needs and the service did not follow Right Support, Right Care, Right Culture (RSRCRC) guidance.

This service scored 32 (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 were at the centre of their care and treatment choices and they did not work in partnership with people, to decide how to respond to any relevant changes in people’s needs. We found care records evidenced people were not supported with their PBS plans. Staff did not follow the plans and the actions that they took were inappropriate and escalated situations and on occasions caused more distress to people.

There were some shortfalls in how the provider understood the diverse health and care needs of people and their local communities, so care was not always joined-up, flexible or supportive of choice and continuity. We found that staff were not trained to support people’s diverse health needs. The service could not evidence the eligibility and funding for people’s needs and were not assured on the amount of support and person needed. They could not evidence where referrals had been submitted to review changing needs of people. However, there was clear communication between the staff around people’s care and support needs. Any appointments pending or attended, and action taken following guidance received from relevant health professionals.

The provider did not supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs. The service did not have an accessible information standard’s policy. They could not evidence that information was provided in formats to support people with learning disabilities or sensory loss. The service had a general data protection regulations (GDPR) policy in place, but it was not relevant to their service. Staff were not trained in GDPR. The service could not evidence that people were given guides that provided clear information around terms and conditions of the service.

The provider did not make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. We reviewed the service’s complaints file and noted it was empty. We were informed by the registered manager that there had been some complaints about the service, but they could not evidence that they had been investigated and responded to appropriately. We were informed by the registered manager regular meetings were held with people living in the service to discuss meal options they did not confirm any other discussions were had and could not evidence the meetings occurring. Limited feedback surveys were completed with people in the service although they were not robust and were completed by staff who the feedback was about. Staff were not asked for their feedback and meetings with staff were not held. There was no process in place to prompt feedback and the service had no improvement plan in place.

The provider did not make sure that people could access the care, support and treatment they needed when they needed it. We identified concerns within the environment and when the provider tried to rectify them their actions did not think of the people living in the service and of their care and support needs. For example, the service removed a bath hoist without discussing this with the person that used this and the impact this would have on them. This triggered a safeguarding concern, the person ran themselves a bath and got stuck and required support and equipment to get out. As a result, the bath was boarded up so unable to use. This restricted the person’s care and support needs.

Staff and leaders did not listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not tailored in response to this. We found that only a small number of staff had completed equality, diversity and inclusion training. We found staff practice did not reflect that people who were likely to experience inequality were supported. On review of care records, we found one person was not allowed to use a communal toilet and was asked to use the one in their ensuite. When the person became upset, they were told their bad behaviour would be overlooked if they stayed in their room for 3 hours and they would be rewarded with a drink. However, the provider had an equality, diversity and inclusion policy in place, but on review of the records it was not being followed.

People were not always supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life. Staff were not trained around end-of-life care when it was suitable for the needs of people living in the service. However, we found people had a recommended summary plan for emergency care and treatment (ReSPECT) form in place and they were clear for people that wanted to be resuscitated and those that did not. People had recorded their goals and plans for the future.