Glendon House

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 remained Good. This meant people were safe and protected from avoidable harm.

This service scored 63 (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. However, there was not a system in place which ensured all lessons were routinely identified, captured and embedded into good practice.

Lessons learnt were being written on the back of incident, accident and safeguarding forms and were not being collated centrally, which meant they could be overlooked and not implemented.

Staff told us lessons learnt were being discussed at handovers, and at staff meetings. However, not all these meetings were documented to ensure those not present could read them and to show an audit trail and help monitoring of changes made.

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.

On admission the registered manager worked with people and their families to ensure the transition into the service went well. They visited the person before they were admitted completing a pre-admission assessment which formed part of their initial care plans. They provided a welcome information pack on arrival. There were very few transfers out, but when there had been they worked closely with the new service, invited them to meet the person and ensured they provided all relevant information to ensure a smooth transition. A relative told us of the admission, ‘The home managers took charge of the situation. They were brilliant. [person] was very well looked after.’

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 registered manager had shared appropriate events with the local safeguarding team, however, we identified these had not all been reported to CQC, which was a regulatory requirement. The registered manager was responsive and adjusted their processes to ensure these were sent. Staff feedback showed they understood different types of abuse and knew how to report it if they were concerned about a person, even though the mandatory training records did not show all staff were up to date with their safeguarding training.

Relatives we spoke to felt people were safe. One told us, ‘I know [person] is safe and sound here, kept clean and tidy, [their] clothes too and well fed.’

Deprivation of Liberty Safeguards authorisations had been made when needed and there was a system in place to monitor these.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People and their families were involved in managing their own risks and staff knew people well. Outside people’s bedroom doors there were cut out pictures hanging to guide staff. For example, a leaf if they were a falls risk, a doll if they were subject to a Deprivation of Liberty Safeguard authorisation. We observed staff redirecting a person who was walking with a purpose towards another person who did not like people in their personal space. This was done discreetly and gently. The service supported positive risk taking. For example, one person, who lacked capacity and was at risk of aspirating, would not take their drinks with thickener added. The service involved the speech and language therapist and occupational therapist with the family to make a decision in their best interest, which weighed up the risk of aspirating with the risk of dehydration and quality of life.

Relatives told us they felt risks were managed appropriately. One said, ‘They do. They have installed crash mats to monitor if [person] falls or falls out of bed.’ This demonstrated proactive measures were in place to reduce the risk of injury and keep people safe.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment and facilities supported the delivery of safe care.

On our first visit we found not all the window restrictors conformed to the relevant guidance, bathrooms cupboards were found open with products, which posed a risk to people, were accessible, and exposed hot pipework in a bathroom. These posed a risk of people being harmed. The registered manager took action before our second visit and afterwards to ensure these issues were resolved.

We raised concerns regarding the staircase to the two upper floors. Some people had poor mobility and lacked capacity to understand they may come to harm using the stairs. People had previously fallen off the last couple of steps and received injuries. There was a risk assessment in place and people who were known to use the stairs also had a personal risk assessment in place. There was also a lift present that people could use.

Systems were in place to manage environmental risks, such a legionella testing reducing the risk of water-borne infection and supporting a safe care environment. Equipment was monitored and serviced in line with manufacturer’s guidance ensuring it remained safe to use, reliable and fit for purpose. The service offered a range of communal areas for people to use, which were also accessible for people living with dementia. These spaces included familiar and comforting items such as newspapers, scarves, handbags, and soft toys to support engagement and reminiscence. Display boards were used effectively, including a “life advice” board where people shared words of wisdom with others, as well as seasonal boards that reflected past celebrations and promoted forthcoming events. The service recognised and celebrated occasions such as Easter and St Patrick’s Day, helping to create a welcoming and inclusive environment.

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.

From our observations and feedback received there were enough staff to meet the needs of people. There was a dependency tool used to ensure there were sufficient staffing to support people.

Staff told us they had the required training to meet people’s needs and their competency was assessed. Staff told us that when they were newly appointed or had been promoted they worked with more experienced staff on shadow shifts to ensure they were competent and confident in their abilities for the role before working on their own. Agency staff when they first started working at the service also worked with experienced staff initially to ensure they were competent. This helped ensure all staff had the capabilities and skills to meet people’s needs.

Staff reported they felt supported by regular supervision and that their views were listened to, helping them feel valued and enabling them to raise concerns and improve practice.The provider also ensured staff were safely recruited, including completing Disclosure and Barring Service (DBS) checks, which looked at an applicant’s criminal record and confirmed they were safe to work with people living in the service.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Relatives told us about the cleanliness. One said, ‘It’s an old building which takes some maintaining. I’ve no concerns though as it is light and airy and there’s never any smells.’ Another said, ‘Yes it is [clean]. The building has lots of character and is airy, light and lovely and clean.’

Staff knew how to use personal protective equipment (PPE) to keep people safe and had sufficient supplies. There was a cleaning schedule in place and audits were taking place on infection prevention and control. These systems helped ensure safe infection prevention practices were consistently followed throughout the service.

The provider did not always make sure that medicines and treatments were managed safely to meet people’s needs. Staff did not always follow processes in place which put people at risk of not receiving medication as intended.

When we first visited the service, we found the medication room was untidy and dirty with medication spillages and unnecessary items stored there. We also identified there were missed signatures and inaccurate counts of medications as part of the medication administration process. Not all protocols for ‘as and when’ medication (PRN) were in place. The registered manager had resolved the issues regarding the medication administration process by our second visit. However, the PRN protocols were still not all in place and the medication care plans were generic and did not detail a person’s capacity to consent to their medication, their needs or preferences, what medication they received, what it was for and any side effects to be aware of. This meant people were at risk of not receiving their medication as intended.

Staff completed training and competencies before administering medication and medication audits were taking place.

Overall people and their relatives, felt medicines were managed safely and were informed of any changes. One relative told us, ‘They appear to manage well. A couple of years ago they reduced or added tablets but we were kept informed.’