Glebe House

Updated 14 October 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by one inspector, a pharmacist specialist, and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Glebe House is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed the information we already held about this service. This included details of its registration, previous inspection reports and any notifications of significant incidents the provider had sent us. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We sought feedback from the local authority and professionals who work with the service. We used all of this information to plan our inspection.

During the inspection

We spoke with six people who used the service about their experience of the care provided. We spoke with six members of staff including three care staff, one nurse, the deputy manager and the registered manager.

We reviewed a range of records. During the inspection we reviewed medicine administration records and care plans. This included two people’s care records and multiple medicines records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

We continued to seek clarification from the provider to validate evidence found, this included risk assessments and updated information about medicine management.

Updated 14 October 2022

About the service

Glebe House is a residential care home which was providing personal care and treatment for injury, disease and disorder to 11 people at the time of our inspection. All people living at the service had mental health conditions. The service can support up to 12 people in one adapted building over two floors.

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

Medicines were not always managed safely. We found gaps in people’s medicine administration records. Protocols for staff to follow when people were prescribed to take medicines as and when required, were incorrect in one instance and missing in another. The provider had not realised there were concerns with medicines management as their quality assurance systems had not identified the issues we found.

Following the inspection, the provider sent us evidence to indicate they had made changes to improve medicines management.

People were kept safe. There were systems in place to help protect people from abuse. People’s risks were assessed and monitored. There were enough staff working at the service and recruitment processes were robust. Infection control practice sought to keep people safe from infection. Visitors were permitted as per infection control guidance. Incidents and accidents were recorded, and actions completed which showed the service learned lessons when things went wrong.

A positive person-centred culture was promoted. People and staff thought highly of the service management. The provider understood duty of candour and acted appropriately in this regard. Staff understood their roles. The registered manager fulfilled the service’s regulatory requirements. People and staff were able to be engaged and involved with decisions that affected the outcomes of the service. The service worked with other agencies to the benefit of people using the service.

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 on 27 March 2019.

Why we inspected

We undertook this inspection as part of a random selection of services which have had a recent Direct Monitoring Approach (DMA) assessment where no further action was needed to seek assurance about this decision and to identify learning about the DMA process.

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.

Enforcement and Recommendations

We have identified a breach in relation to safe care and treatment at this inspection. We have also made a recommendation to follow best practice guidance around quality assurance.

The overall rating for this service has now changed from "Good" to "Requires Improvement."

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

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.