Glendon House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service

This service scored 62 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Relatives told us the registered manager was open, transparent and approachable. They felt confident any concerns would be listened to and addresses promptly, which supported positive relationships between families and the service.

The registered manager had fostered a supported culture in which staff felt valued. Staff reported that they were able to provide feedback, raise concerns and access support when needed.

The management team worked effectively with external professionals and agencies, including health care teams, social workers and local authorities, helping to ensure people received well-coordinated and effective care

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The registered manager had worked to change the culture of the service when they first started. They had developed roles, were clear on expectations and responsibilities of the different staff. They and their deputy manager had made themselves visible within the service to speak to staff, visitors, people and their families to pick up concerns and also what was going well.

The management team valued staff contributions and actively sought their views. Staff told us the registered manager was approachable and knowledgeable, and they felt the management had improved since the registered manager had started.

When people and their relatives were asked, what was the most important thing about the service to them, they identified the manager. One person said, ‘[Manager]’s open to people, you can talk to [them] and [they] talk to you, [they] have time for you. For me that’s the most important thing.’ Another said, ‘[Manager]’s a total joy to spend time and chat with,’ and, ‘It all radiates from the manager.’

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The registered manager was known by people and their relatives. They sought feedback in person and via surveys. There were also regularly staff meetings and handovers each day, where staff could raise concerns and discuss topics.

Staff felt they could raise concerns with the manager and felt listened to, knowing they would be investigated. One said, ‘Yes our manager goes above and beyond and deals with problems straight away.’ There were policies in place such as whistleblowing and complaints.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff reported feeling well supported by the management team, both professionally and personally. They described an environment where they felt listened to, valued and this contributed to a positive workplace.

The provider did not have clear responsibilities, roles, systems of accountability for good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The systems in place were inadequate to give oversight and monitor the service. The audit schedule and monthly audit checklist did not match in what audits should be completed in what month, and the audits were behind in being completed. Some completed audits did not cover all the areas to give oversight. For example, the care plan audit did not check such things as monitoring forms, or daily notes to ensure any issues were identified. We identified gaps in bowel monitoring and personal care charts which had not been investigated to ensure appropriate care and actions had taken place.

There was no overview of the care records themselves to identify contradictions, gaps or missing information, which we had identified during this inspection, such as contradicting information in a person’s Personal Emergency Evacuation Plans (PEEPs) on the number of staff needed to support. This meant the care records in place did not provide consistent, complete guidance for staff to follow which put people at risk of not receiving the required care.

There was lack of identifying themes and trends for areas such as incident, accidents, complaints and safeguarding referrals. Due to this, lessons learnt were not all identified and there was no system to ensure all lessons were fully implemented. When lessons were identified they were written on the back of the recording forms with no central record and no clear oversight. This meant there was a risk some events could be repeated if all lessons learnt were not implemented.

There was a lack of documenting staff meetings which meant staff who were not in attendance did not have minutes to refer to. As a result, there was no clear audit trail to evidence key information had been shared, increasing the risk of inconsistent communication and staff not being fully informed about changes or expectations.

There was a lack of oversight on staff training and competencies. Although this was in place there was no matrix for competencies. This meant the manager did not have information to know when staff were due competency checks, which could lead to a lack up to date skills to provide safe and appropriate care.

We reviewed a large number of environmental risk assessments which were similar, for example laundry and soiled laundry, extreme heat and ventilation. Others had gaps, for example, influenza covered staff but not the impact of people who lived in service. This meant that not all risks were being managed in a safe way.

The registered manager completed a monthly report for the Nominated Individual (NI) but this did not cover such areas as audits, complaints, safeguarding referrals or lessons learnt. There were also quarterly meetings between the NI and registered manager. However, it was not documented that complaints, findings from audits, incidents, safeguarding referrals or lessons learnt were discussed. This meant the review of the governance system and how the service was performing was incomplete limiting the provider’s ability to identify risks, monitor improvements, and ensure effective oversight.

The NI worked closely with the registered manager and completed a monthly unannounced visit where they spoke to people and staff, inspected the premises and records. However, when issues were found they were not recorded as actions. One visit record stated there was some missing information from a care record but did not state what it was or identify any action from it. As a result, there was limited assurance that concerns were addressed, actions were completed or improvements were monitored, increasing the risk that identified issues remained unresolved and governance oversight was ineffective.

Overall this meant that although the governance systems intended to monitor and improve quality were in place, these were not complete, effective or consistently implemented to drive improvement. Leaders did not maintain the level of oversight needed to ensure that improvements were made, embedded and sustained.

The registered manager worked on issues with the governance system whilst the inspection was in progress to make improvements.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The service was one of two under the same provider. The registered managers shared information and learnt from each other.

People were supported to attend healthcare appointments when needed. Staff worked closely with health care professionals to support people especially as their needs changed. There were good systems in place to monitor referrals to health care professionals to ensure timely responses.

Staff liaised with the local GP surgery and had regular visits from staff from the surgery. Health care professionals felt the service always communicated clearly with them regarding people’s needs and listened to advice and guidance given.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

Since starting in the role, the registered manager had developed and embedded systems to improve quality of care and strengthen governance. They had been focussed on problem solving and implementing new systems but had not taken time to review what was in place to ensure it was fit for purpose.

The management team had listened and responded promptly to questions and concerns raised as part of this inspection. They had made changes and improvements. The registered manager was keen to acknowledge and implement new ideas where they could improve care.