Glebe House

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

This service scored 46 (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 make sure people’s care and treatment were effective.

Robust processes were not in place to ensure the service was able to meet the needs of people.

Before a person started to use the service, the registered manager carried out an initial assessment. Information was also gathered from relatives and from the commissioning team to ensure the service had all the relevant details on what the person’s needs were and how to meet them. However, we identified that not all assessed information around people's needs was included in their care plans and risk assessment. For example, we saw a lack of guidance in place for 1 person’s paper care document folder for choking risks relating to when staff needed to call the emergency services. We subsequently discovered that the updated information was in place and stored on the computer; however, staff were unable to access it because the system was password-protected. As a result, this may have placed individuals at risk of harm.

We also saw that that not all information from assessments was included in care plans and risk assessments regarding changes of people’s health needs, such as being diagnosed with dementia since being admitted into the home. This meant people were at risk of unsafe care if staff were not aware of people’s individualised needs.

A staff member reported to us that they sometimes found it difficult to stay fully informed about changes people’s needs. This was due to care records not always being updated promptly or lacking sufficient details. The lack of robust systems to assess people’s needs in a timely manner meant people may not receive safe and effective care at all times.

The provider did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them.

People’s care records were not always consistent with how people needed to be supported, or how the support would be delivered to the person. For example, we saw no informationin care plans as to how people were to be supported with dementia care and the possible impact on the person if staff did not provide support appropriately.

We did not see evidence that tools and aids such as pictorial communication or the use of different colours in the environment was being used to support that person.

The provider did not always work well across teams and services to support people.

During our visit, the registered manager informed us that a person was recently discharged from hospital. The home identified a health concern with the person following the discharge; however, they did not contact the hospital to discuss their concerns with them. This meant that the service did not always work with other health professionals, to ensure the person’s wellbeing. We discussed our concerns with the registered manager who advised us that they would raise a safeguarding due to unsafe discharge.

Staff did not always communicate well between themselves and did not always work well together. A staff member told us, “The environment is very [negative], it lacks respect, accountability. No teamwork.” Another staff member said, “Terrible teamwork, staff don't like changes.” A person said, “There are some good staff that respond to requests well. However, not all staff communicate with each other like when they told me that they will pass my request on to the manager, which don’t always happen”.

We discussed the feedback with the management team who told us that they had worked with the team to help bring them together.

The provider did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. Staff did not always support people to live healthier lives, or where possible, reduce their future needs for care and support.

Records showed that people attended health care appointments. Staff told us they could identify if people were not well and knew what action to take in an emergency. People were supported to maintain their health and were referred to health services such as the local GP, district nurses. However, we also identified that not all referrals had been completed when concerns had been identified. For example, we saw that a person’s mobility had declined, there was a delay in requesting an occupational therapist assessment, placing the person at risk of not receiving timely and personalised support.

Care plans did not always have up to date information on people’s changing needs, which meant that staff did not have access to information to ensure people received safe and effective care at all times. For example, a person had been recently diagnosed with a medical condition, and this information had not been added to their care plan.

We reviewed healthcare information in peoples care files that was crucial for hospital admissions to ensure continuity of care. However, we found it had not been updated recently. For instance, one person's hospital passport lacked current details on their health changes.

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

We found the provider’s audits and quality systems had not identified that people were not always receiving and experiencing high quality care and achieving positive outcomes. This meant there was a lack of oversight and effective auditing to identify issues and make continuous improvements. For example, the service needed to be redecorated due to the poor condition the environment was in. This was also identified by the local authority’s quality team in April 2025 but was only being completed at the time of our assessment. Another example wassome people had not had a care plan review since 2023. We also found people's support needs had not been recorded in their care plans after being assessed by health professionals.

Since our assessment the registered manager had reviewed people’s care plans and updated the information as required. They had also completed referrals to health professionals, such as occupational therapists.

The provider did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.

Some people told us that they were able to make their own choices; this included, when they wanted to get up and what they wanted to eat. However, we identified that there was a lack of detail within people’s completed mental capacity assessments and best interests forms. For example, a person’s mental capacity assessment stated that they had capacity when they did not have capacity. Information was not clear on what the specific decision was being assessed. The assessment stated environmental concerns but did not specifically state what the concerns being assessed were, and the information did not mention how the decision was being made and what tools were being used to help the person to understand what was discussed.

We received feedback from the local authority that they saw the registered manager completed an MCA without the person present and or family input. This meant that decisions were being made without the correct procedures being followed. We discussed this matter with the registered manager.

During our assessment, we also identified concerns with people’s MCA assessments. For example, there was information that family was consulted, but did not state if the family member attended the meeting and how they were involved in the process. The information was not clear as to what professionals were involved and if it was considered if the person needed any advocacy support.

The above issues meant people were at risk of not being assessed correctly in line with theMental Capacity Act.

The management team ensured authorisations for Deprivation of Liberty Safeguards (DoLS) were in place for people whose liberty was being deprived.

Following the inspection, the management team reviewed people’s mental capacity assessments and best interest forms to ensure those adhered with MCA principles.