Archived: Glen Heathers

Glen Heathers is a residential care home providing personal and nursing care to up to 53 people. The service provides support to older people including people living with dementia and/or a physical disability. At the time of our inspection there were 24 people using the service. Glen Heathers accommodated people in one adapted building.

People’s experience of using this service and what we found

People were not always prevented from receiving unsafe care and treatment. People were at risk of harm because risks to them were not always assessed or mitigated.

Incidents including safeguarding concerns were not always recognised, reported or investigated. There were concerns about the safe management of; medicines, infection control, staffing and recruitment.

The provider had failed to make enough improvements since the previous inspection and has a track record of not providing good standards of safety. We continued to receive feedback from people and relatives which raised concerns about the safety and quality of care.

The delivery of high-quality care is not assured by the provider’s system in place to assess, monitor, and improve the service. A manager is in post and we received positive feedback about their impact on the service culture. However, leadership in the service has been stretched and inconsistent which has meant progress since the previous inspection has been slow and improvements have not always been sustained.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was inadequate (published 12 November 21)

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.

Why we inspected

We received concerns about people’s safety and as a result, we undertook this focused inspection. In addition, we carried out an unannounced focused inspection of this service on 13 September 2021. Breaches of legal requirements were found. The provider completed an action plan after that inspection to show what they would do and by when to improve notifications of other incidents, safeguarding service users from abuse and improper treatment, premises and equipment, safe care and treatment, good governance and staffing.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the key questions safe and well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has not changed from inadequate. This is based on the findings at this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Glen Heathers on our website at www.cqc.org.uk .

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to the safe care and treatment for people, staffing, safeguarding people from abuse and improper treatment, fit and proper persons employed, governance and notifying CQC of incidents.

We issued a Notice of Proposal to remove this location from the providers registration. The provider did not submit any representations against this Notice so we issued a Notice of Decision. We have now removed this location from the provider's registration. This service is no longer operational with effect from 6 June 2022.

Glen Heathers is a care home providing personal and nursing care to 33 people aged 65 and over at the time of the inspection. The service can support up to 52 people.

People’s experience of using this service and what we found

People did not receive a service that ensured they were safe and received the care they required.

Safeguarding concerns were not fully investigated and recognised. Medicines management required improvement to ensure it was safe. The home was unclean, cluttered and poorly maintained. Good infection control measures were not being undertaken.

Staffing levels, skill mix and deployment did not meet the needs of people and placed them at risk.

People's care plans and risk assessments did not always contain the information needed to guide staff how to meet their needs and keep them safe. Where risks were known, people did not receive the care and support they required to reduce these risks.

Staff in leadership roles did not always promote the delivery of high-quality person-centred care or act in an open and transparent way. Governance processes were ineffective. When things went wrong in the service, we were not assured these were incidents were analysed effectively, and lessons were learned and applied to reduce the risks to people and ensure their safety.

Following the inspection the nominated individual (NI) for the provider changed and therefore within the body of the report the NI referred to is the previous NI.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 7 May 2021) and there were multiple breaches of regulation.

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected

We carried out an unannounced focused inspection of this service in March 2021. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve staffing, governance, safe care and treatment and the requirement to notify CQC of certain incidents.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from Requires Improvement to Inadequate. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Glen Heathers on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to the safe care and treatment for people, infection control, staffing, medicines, the environment, safeguarding, governance and notifying CQC of incidents.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up: We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Special Measures: The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within six months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

About the service

Glen Heathers is a care home providing personal and nursing care to older adults and can support up to 53 people, although now choose to only support up to 40 people. At the time of our inspection there were 36 people living in the service.

People’s experience of using this service and what we found

Staff and people told us they felt there were not always enough staff to ensure people's needs were safely met.

There were systems and processes in place to assess and monitor the quality of the service, however these systems did not identify the shortfalls we found. The culture at the service was not always positive and staff morale was low.

People were not always protected from the risk of avoidable harm. Risk assessments were not always in place, were not consistent, or did not provide staff with the information they needed to ensure people received safe care and support.

We could not be assured staff had received appropriate training in a timely way to enable them to carry out their role safely. The provider and registered manager had failed to notify CQC of significant events without delay, which they are required to do.

People’s medicines were managed safely. The service worked in partnership with health and social care professionals to provide joined up care.

We had mixed views from people’s relatives about if they thought the service was safe and if they were kept informed of information throughout the coronavirus pandemic.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was Good (published 16 July 2019).

Why we inspected

The inspection was prompted due to concerns we had received about infection control practices, the potential neglect of people receiving care, allegations of verbal abuse and staffing levels. A decision was made for us to inspect and examine these risks. We undertook a focused inspection to review the key questions of safe and well-led only.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Glen Heathers on our website at www.cqc.org.uk.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection and we have found evidence that the provider needs to make improvements. Please see the safe and well led sections of this report.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to the management of risks associated with people's needs, staff training, staffing levels and governance systems.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan and meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good.

Glen Heathers is a residential care home providing personal and nursing care to 33 people aged 65 and over at the time of the inspection. The service can support up to 53 people.

People’s experience of using this service and what we found

There were enough staff available to support people. The environment was clean and people had access to appropriate equipment where needed. Medicines were administered safely and as prescribed. Risks associated with people’s needs had been assessed, were understood and managed by staff, which meant people were safe from harm.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. Staff had received appropriate training and support to enable them to carry out their role safely. They received regular supervision to help develop their skills and support them in their role.

People were supported by staff who showed kindness, compassion and respect towards them. Staff maintained people’s privacy and dignity whilst ensuring they were involved in decisions about their care.

Staff’s knowledge of people’s history, preferences and risks associated with their care and support needs was good. Differing communication needs were recognised and where required information was presented in an accessible format. Activities had improved, and people accessed the community if they chose to. People knew how to raise concerns.

People had confidence in the registered manager and told us they would recommend the service to others. The registered manager was open and transparent. They understood their regulatory responsibility and engaged people as much as possible. A quality assurance system was in place to assess and monitor the service, which had led to improvements for people.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was Inadequate (published 30 August 2018). Since this rating was awarded the provider has changed its legal entity. We used the previous rating to inform our planning and decisions about the rating at this inspection.

During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.