Glenkindie Lodge Residential Care 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

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 people’s safe care and treatment, risk management, infection prevention and control and medicines management.

This service scored 44 (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 always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The provider had a system and process in place to monitor incidents and accidents, which included analysis of the information, and this took place on a regular basis. However, we found that learning did not take place following this, and incidents and accidents of the same, or similar nature occurred at a high frequency, often with the same people involved.

Some staff told us that they had previously raised concerns with managers and leaders, and they were not assured these had been investigated as they had not received updates or communication and had not seen changes in practice.

The provider was receptive to our feedback throughout the assessment, and began to make changes, however, these were not embedded into practice by the end of our assessment.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

There were systems in place for emergencies. For example, the provider ensured that people had their own Personal Emergency Evacuation Plans (PEEPs) and an emergency bag for staff to utilise when required. There was room for improvement to ensure the PEEPs were in a format that supported quick access to information to support a smooth evacuation.

People were not always referred to relevant external professionals when necessary. For example, where people had a history of falls, or had begun to experience falls more frequently, they had not been referred to falls teams, or other professionals who could support them with this need.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always 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 always share concerns quickly and appropriately.

There were safeguarding policies in place, which detailed a clear process and contained relevant information. Staff had a good understand of their role in safeguarding people, however, we found that there was a high level of unexplained skin tears, unexplained bruising and unwitnessed falls. These incidents often did not have any follow up actions, and at times, were not reported to the appropriate external agencies, such as CQC.

Where people were deprived of their liberty and required a Deprivation of Liberty Safeguard (DoLS) authorisation in place, these were applied for by the provider and there was a system in place to keep track of expiry dates. However, some people’s DoLS authorisations had conditions attached to them, including specific actions the provider should take, and these were not always fully adhered to.

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.

The provider did not provide adequate detail within people’s care plans and risk assessments for staff to safely manage and mitigate risks. For example, where people required support with bowel management, there was a lack of detail and guidance for staff on what actions they should take, and how to identify a concern and escalate this to the relevant professionals. We did not find significant impact for people, however, did identify potential impact and risk as some people’s records indicated cause for concern, that had not been escalated to relevant professionals.

Relatives told us that they had not been involved in decisions about people’s care, and some people told us they had also not been involved, nor been shown their plans and assessments.

Staff told us that risk assessments and care plans were basic and did not contain enough detail in them to enable staff to do their job safely.

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.

The provider had systems in place to monitor safety within the service, however, during a recent change in maintenance systems, some of these processes had lapsed and we found some risk assessment reviews were overdue.

The provider had made some improvements to the environment since they took over in February 2025. They had developed, and were working to an action plan, however we were not assured that items within this action plan had been prioritised efficiently. For example, the provider had identified that the layout of the communal areas was not accommodating of people’s mobility needs. This had been identified in October 2025, reviewed in January 2026, but no further action had been taken to mitigate the risk to people’s mobility, nor had any interim measures been put in place.

The provider did not always 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 always work together well to provide safe care that met people’s individual needs.

Staff were not always recruited safely. Most processes were thorough, however, managers and leaders did not all understand how to properly use the Disclosure and Barring System (DBS) update service, meaning some staff had not been sufficiently vetted prior to their employment.

We were not assured that staff were deployed effectively. The provider used a dependency tool to determine what level of staffing it required, and they were operating in line with this. However, they had not considered that communal areas were often going without supervision, putting people at increased risk of harm, for example, from falls. We found that most communal areas were unsupervised throughout our assessment.

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 provider had policies in place in relation to infection prevention and control, but these were not always adhered to, for example, the provision of hand sanitiser throughout the service.

There were systems and processes in place to monitor daily, weekly and monthly cleaning tasks, however, these were not being utilised and there was not adequate oversight.

Staff did not always utilise facilities available to them, to support people to maintain their personal hygiene. For example, we observed staff supporting people to wipe their hands using ‘baby wipes’ before consuming food, in place of washing their hands.

Control of Substances Hazardous to Health (COSHH) products were stored and organised effectively, additionally, the laundry service was well organised and the area kept clean and hygienic.

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

Medicines were not safely managed, and there was a lack of oversight as the provider relied on system generated processes.

We found that the provider did not complete physical audits of medicines, therefore had not identified stock piling, out of date medicines, inadequate storage facilities and some medicines not being administered in line with their prescription labels.

Some relatives and people told us that medicines are often not given at the correct times, and on occasion had not been given at all.

People were not supported in line with their preferences, for example, one person preferred their medication in the early evening before they went to bed, however, they were regularly not supported with this and would be woken up later in the evening to take their medicine.

The provider had a system in place for regular checks of the temperature of medication storage facilities, however, there was no process for staff to follow when the temperature was found to be too high. We found that some medications had been stored at a temperature above what was instructed on the manufacturer’s guidance, for 3 days. The provider took prompt action when this was raised with them.