Archived: Glenholme

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 inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulations in relation to people’s safe care and treatment, safeguarding people from abuse, staffing and fit and proper persons employed. The were concerns identified regarding the safety of the premises and the risks posed within the service. Incidents were not being reported within the service and notifiable incidents were not reported to the local authority. Staff were not trained and competent to meet people’s needs and there were poor recruitment checks to ensure suitable staff were employed.

This service scored 31 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify, improve and embed good practice. We identified the provider’s accident and incident policy was not a clear process for staff, there was no evidence of checking people over for injuries following an accident, staff were not following the policy. There was no evidence of safety events being reviewed and shared between the teams. The service had a complaints log, but this was not an accurate reflection of the complaints within the service and there was no evidence of appropriate investigations conducted where concerns had been identified. The service had no improvement plan in place at the beginning of our assessment. The registered person said “We do not have a lesson learnt process.”

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. There was no evidence of referrals being submitted to relevant healthcare professionals to support people’s care and support needs although we were told by the registered manager they were submitted. They informed us of delays in getting appropriate support for people in the service, although could not evidence any measures they had implemented to support people until appropriate professional support was sought. There was no evidence of pre-assessments being carried out when people moved into the service. However, staff told us they were informed of new admissions. One staff member we spoke with said, “Information about new people, we receive spoken communication from the manager about new people, and we are encouraged to read any accompanying documents describing the person's health issues, care needs and lifestyle choices.”

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately. We found safeguarding concerns were not reported to the local authority or the Care Quality Commission (CQC). Incidents were not always recorded and ones that were, were not investigated. Not all staff were trained in safeguarding and were not competent in raising safeguarding concerns. During our assessment the provider ensured staff had completed safeguarding training but had not ensured the staff were competent in raising concerns. There was no clear policy for the staff to follow and the service had no policy or procedure on duty of candour, this means the service could not evidence that when something goes wrong they acted in an open, honest and transparent way. However, some people had authorised deprivation of liberty safeguards (DoLS) in place to ensure they were protected from harm and people we spoke with felt safe.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. We found that people’s care and support needs were not always appropriately risk assessed and this put people at risk of harm. People had risk assessments in place completed 11 years prior and staff did not understand the meaning of them or their purpose. There was no evidence of risk assessments being regularly reviewed or as and when needs changed. People had specific health conditions and staff were not appropriately trained to support people’s individual needs. PBS plans were in place, but these were not being followed. People were not always empowered to take appropriate risk taking. People were not encouraged to make their own meals or do their own laundry. However, they were encouraged to help clean the environment to help support their independence.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care. We found that the service did not ensure safety equipment was checked. A bath hoist had not been checked to ensure it met the Lifting Operation and Lifting Equipment Regulations (LOLER). The service had an external fire risk assessment conducted and actions were outstanding and had not been reviewed. People’s personal emergency evacuation plans (PEEPS) were not robust and did not clearly identify risks posed and had not been reviewed for several months. Staff had not completed adequate fire safety training. They had not carried out adequate fire drills and could not evidence that people in the service could evacuate safely. The service had no environmental risk assessments in place to mitigate risk. We identified the service had been aware of ongoing failed water checks and had not taken any action to rectify the issue. The furniture was not secure in people’s rooms and posed a risk. The service had no policies on the health and safety of the environment.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs. We found gaps in recruitment checks. They were not robust and did not include people’s employment history, lacked references and some staff did not have enhanced data barring service (DBS) checks in place. Staffs’ health was not assessed. The service did not have a dependency tool in place so they could not be assured they had enough staff. We found there were not enough suitably deployed staff to meet the needs of people using the service. There was only a small number of staff that had a supervision conducted in the last year. All other staff had not received a formal supervision and no staff member had received an appraisal. Staff had not been assessed on their competency in any area of their job role by a competent individual. We found staff had not completed mandatory training within the service and had not completed the care certificate standards. There were no policies in place on recruitment and the training policy was limited. However, Following our initial visit where we identified and raised concerns with the provider, the service increased their staffing levels and implemented measures to address some of these shortfalls.

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. We observed the environment and found it to be visibly unclean. We saw a build-up of dust and rust in the environment and general wear and tear concerns around the property. Infection prevention control (IPC) audits were conducted, but we found they were ineffective and did not include visually checking the environment. The service had an IPC policy, but it was limited on the information it contained and did not explain the procedure for staff to follow to ensure the environment met IPC standards. The service had a clinical waste bin stored within the kitchen. We addressed the concerns with the registered manager and they removed the clinical waste bin. They arranged a deep clean at the service, but we were not assured this was embedded practice at the service. However, people we spoke with did not have concerns over the cleanliness of the environment. One person we spoke with said, “I have my jobs I do around to help keep it tidy.”

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

There were some gaps in the information available to manage some people’s medicines safely. The administration of medicines prescribed for occasional use when needed at the discretion of staff (PRN medicines) are recommended to have protocols in place to inform staff when the medicine should be administered. Some people did not have these in place. Some risk assessments about people’s medicines had not been completed and fully signed off.

Topical medicines were not all being handled in a way that would ensure they were not in use for excessive periods of time. Body map information about their areas of use on the body were not always in place. The registered manager confirmed that staff authorised to give people their medicines had not recently had their competence assessed to ensure that they did so safely. We raised a concern that staff currently administered people’s medicines in a busy area of the home that could lead to staff being distracted and mistakes being made. However, records we checked showed that people received their medicines as prescribed. Medicines were stored securely and at correct temperatures. There was information available for staff about how people prefer to have their medicines given to them.