Glebe 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 requires improvement. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and health and safety and the management of people’s medicines.

This service scored 34 (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 have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

At the time of our inspection, we found that not all Lessons were learnt to continually identify and embed good practice. For example, various audits had not been fully embedded into routine practice, such as learning from lessons following incident limiting the provider’s ability to effectively mitigate risks or identify emerging themes and trends to minimise risks of incidents.

Some staff told us that they did not feel listened to when they raised concerns about safety. A staff member told us, “No feedback is given on any learning from incidents.”

People’s care records did not always reflect the learning that took place when incidents had happened. There was a lack of guidance within care records for staff to follow in ensuring people were supported safely. For example, we noted that there had been incidents involving one person living at the service where staff were required to call the police for assistance. Lessons had not been learnt from the incidents, and we did not see evidence that the individual's care plan or risk assessment had been updated to reflect how staff should respond if a similar situation was to occur again. However, after our inspection the provider sent us evidence that risk assessment and Learning had been reviewed, which we were informed that the information was stored on the services computer that we could not access due to it being looked on day 1 of our visit and on day 2 the service had IT issues. As staff was unable to accesses the computer due to the Registered manager not being at the service this potentially put people at risk as they could not access their up-to-date information.

The provider did not always work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care.

People’s needs were assessed before they moved into the service. The needs assessment contained information about the person’s medical, physical, background history and the care and support they required. However, people’s care plans and risk assessment did not always reflect the information which was in the pre- admission assessment. For example, there was a lack of information and guidance for staff on how to support a person with their anxieties on their care plan, which had not been captured from the pre-admission assessment.

Information which people used when attending hospital or medical appointments lacked key information about people’s individual support needs, including recent diagnoses such as early-stage dementia. This meant that systems were not safe to ensure people received appropriate care and support when attending medical appointments.

After our inspection the provider submitted evidence that showed records were in place. However, the records were not available at the time of our assessment as the computer was locked, which also meant that staff did not have access to these records when needed, placing people at risk of not receiving safe and personalised care.

The provider did not concentrate on improving people’s lives or protecting their right to live in safety. They did not share concerns quickly and appropriately.

Safeguarding systems were not robust. During our first site visit, we saw that a person was exposing themselves whilst their bedroom door was opened. A staff member did not acknowledge this until we pointed out this concern to them. When we spoke with the deputy manager regarding this concern, we were advised that this was a new concern, which was identified 2 weeks prior to our assessment and that the person had been assessed in June 2025 and was diagnosed with the early stages of dementia. However, this was not mentioned in the person’s care plan or risk assessment as the records had not been updated since 2023. The deputy manager informed us that the care plan and risk assessment would be updated and made available to all staff promptly following our feedback.

However, on our second site visit, we reviewed the same person’s care plan and risk assessment and saw that they had not been updated. We also saw the person was still in the same situation, as their bedroom door was open and they were again exposing themselves and other people could see into their room. This meant their dignity and safety was not being maintained and protected. This showed that there had not been learning from previous safeguarding concerns, which we had identified during our previous visit.

After our inspection, the provider sent us people’s updated care plans and risk assessment that reflected the concerns that was identified during our visits. Which was not available during our visit and placed people at risk of not receiving safe.

We also noted a person had been discharged from hospital with a redness on their skin that was assessed by the persons GP as a pressure sore. However, we found that there had been a delay of informing the hospital and local authority on the day of the person being discharged regarding the concerns.

We reminded the registered manager of their responsibilities that any safeguarding concerns needs to be reported to the relevant authorities without any delay, which the provider has now sent the relevant safeguarding documents, after our inspection.

We received mixed feedback from people about their safety. A person told us, “Yes, I am safe here.” Another person said, “I don’t feel staff listen to me when I tell them about a concern, for example nothing is done about things that I tell them.”

A staff member told us, “I feel that people areoften ignored, and spoken to inappropriately, or left unattended.” Another staff said, “On many occasions people’s safety is not a priority in the service. This may be due to how situation is handled.”

Due to the concerns, we found during our visit, we made 2 safeguardingreferrals to the local authority and informed the provider. They said they would carry out an investigation regarding the concerns we raised. Following the inspection, they enrolled all staff on training in safeguarding, dignity and respect as well as arranging different workshops to help enhance staff’s knowledge and understanding.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Robust systems were not in place to assess and manage risks to people who lived at the home. During this assessment, we identified that risks about people’s safety were not assessed fully to ensure they were supported to remain as safe as possible.

We found that risk assessments were generic and not comprehensive and did not give details of all the actions staff needed to take to mitigate risks to people. For example, where people were at risk of choking, there was no clear guidance for when staff needed to call an ambulance. Therefore, people were at risk of receiving unsafe care and support, as staff did not have appropriate guidance in place to follow to help reduce risks to people.

People’s risk assessments were not reviewed in a timely manner when required, and up-to-date information was not added when people’s risks had changed. This meant that staff did not have access to people’s current information. For example, the registered manager told us about how they had supported a person around managing their anxieties, however there was no evidence recorded in the person’s care plan or risk assessment on anxiety, which meant that there was a potential risk that staff may not be consistent with their approach when supporting this person.

Following our inspection, the provider submitted evidence indicating that the necessary records were in place. However, these records were not available during our initial visit to the service and only became accessible on day 3. The information had been stored on a computer that was locked, resulting in staff being unable to access the records when required. This lack of access posed a risk to individuals, as it may have prevented them from receiving safe and support.

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

On the day of our visit, we observed that a fire door in the service was not closing fully, due to the fire strip being broken. This placed people, staff and visitors to the service at risk in the event of a fire. We discussed our concerns with the management team who took arranged for an external contractor to fix the door. This was completed on the day of our visit.

After our inspection, the provider submitted evidence showing that monthly checks of fire door equipment had been carried out before our visit. However, the issues identified by inspectors on the day could have placed people, staff, and visitors at risk due to the concerns found.

We saw other concerns that could put people at risk of harm. For example, we observed that there was a hammer on the floor in one of the downstairs bathrooms. This meant that people could have access to it, which was a potential risk to other people. We discussed our concerns with the deputy manager. However, on our second visit, the risk had not been removed as the hammer was still there. This meant that the risk had not been addressed appropriately to ensure that people were kept safe at all times.

We also saw that a side door was kept open with a long plank of wood with nails protruding from it. We informed a staff member, who immediately removed the plank. However, this had not been identified prior to our visit placing people at risk of harm.

Prior to our visit, we received information from the local authority that there were broken toilet seats. We saw 1 toilet seat missing and 2 that were broken. This meant that the service had not addressed the concern that had been identified by the local authority and placed people at risk from infection control issues.

We noted there were restrictors on the windows. However, they did not meet Health and Safety Executive guidance as they could be opened without a tool or key. Also, the window opening was not restricted to 100mm or less. We discussed our concerns with the provider who agreed to arrange for new window restrictors to be installed on all the windows.

There was also a risk the supply of drinking water could become contaminated due to back pressure or back siphonage. We found the shower heads in 2 shower cubicles could drop below the water level when the showers were in use. This was also the case with the shower head in the bath. This could create a backflow (an unwanted flow of water in the reverse direction). Backflow can introduce various contaminants into the potable water supply, including bacteria, chemicals, and other harmful substances. This placed people at risk of harm when using the shower.

The registered manager told us they would take immediate actions to rectify this issue, and they confirmed this had been completed following our feedback.

During the assessment, we were advised by the deputy manager that the call system had not been working for over 3 years. It had not been fixed as the provider felt the system was not required. However, there were no assessments in place to identify that people did not need the system. Our assessment identified that people were not aware that the system was not working. This meant that this was a potential risk that people could use the call system without being aware that the staff had not been alerted and not receive timely support and care to ensure they were safe at all times.

The registered manager said that they would carry out a needs assessment for all people and request assessments from occupational therapists following our concerns with the call bell system. During our second visit to the service, we found that the call points did not have any information displayed to inform people that the system was not working.

Staff carried out health and safety audits within the service. However, this had not identified the shortfalls we found during the assessment. We reminded the provider that staff must remain vigilant in identifying hazards and risks, as failure to maintain a safe living environment places individuals at significant risk of harm.

The provider did not always make sure staff were skilled to identify concerns.

The staff team did not always have the skills to identify potential safety concerns to people and ensure people were always safe living at the service.

We saw staff completed training in different areas to help meet people’s needs and keep them safe. This included, safeguarding, infection control, risk assessing and managing people’s mental health and their anxiety. However, not all training the staff had received helped give them the skills they needed as we identified concerns during our assessment. For example, safeguarding concerns were not always addressed in a timely manner and risk assessments were not always mitigated as required to ensure people were safe from avoidable harm. There was also concern around people’s privacy and dignity. This meant that there was no oversight or checks to ensure staff had the skills and knowledge to perform their roles effectively following training.

The provider had systems in place to carry out relevant pre-employment checks before staff worked at the service. Staff files contained application forms, copies of passport or driving licence, references, health checks and criminal records checks. This helped to ensure people who used the service were not exposed to staff that were barred from caring for vulnerable people.

Staff confirmed that they had received an induction when they started working at the service. We also saw evidence of completed induction forms. This covered a number of areas including training and familiarising themselves with policies and procedures and getting to know people who used the service.

During our assessment, we observed that the provider had an appropriate number of staff members on shift to adequately support people.

The provider had a system to ensure that staff received supervisions on regular basis. Records showed staff received regular supervisions. However, there was mixed feedback from staff about the support they received from the management team. A staff said “I feel supported in my roles. I can speak with the manager for advice and support at any time.” Another staff told us, “I receive, supervisions, however they are not kept confidential so I'm afraid to say anything.”

Following our inspection, the service provided evidence showing that staff concerns have been addressed and that ongoing support measures are in place to help reduce the risk of any further issues arising.

The provider did not consistently assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The provider had a cleaning rota in place for staff to follow. However, we found that not all areas of the home were clean. For example, the ground floor shower room and the first-floor bath needed a deep clean, as there was ground in dirt around the shower tray door and inside the shower tray increasing the risks of infection.

We also observed that the bathroom and shower room floor was dirty and stained and needed to be replaced. The staff team informed us that this had been reported to the landlord. This was a potential infection control concern. The service has since provided us with evidence confirming that the flooring was replaced after our inspection.

We saw that the downstairs toilet extractor fan had not been cleaned and had a lot of debris inside it, which was a potential infection control hazard as well as a fire risk. The provider took action and cleaned the fan following our feedback.

During our visit, we reviewed the local authority’s Infection Prevention and Control (IPC) audit conducted on 17 September 2024. We noted that not all actions outlined in the audit had been completed by the time of our inspection on 27 June 2025. For example, the action plan specified that light pull cords to be replaced with switches or sensors by 3 October 2024, but this had not been carried out. This meant that there was a lack of oversight in ensuring required actions were taken to minimise the risk of infections.

Staff had access to personal protective equipment (PPE) such as aprons, masks, and gloves. Staff received training on how to manage infection control. However, after our visit, we received feedback from staff, who told us that they did not always have access to PPE. We shared the concern with the registered manager, who shared their audits with us which showed that the provider had PPE in place which was ordered on a regular basis.

Failure to have robust infection prevention and control systems in place, placed people at significant risk of harm with infections.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

At our last assessment, we identified medicines concerns relating to the management of medicines, we observed evidence indicating that the previous concerns had been addressed. At this assessment, we identified further concerns and improvements had not been made.

We reviewed the services ‘when required medicines’ (PRN) protocols for a person. It was identified that 1 PRN protocol was missing. However, the registered manager printed it out when this was highlighted to them. This meant that the nurses did not have this information in place if they needed to check the PRN protocol. Staff who administered medicines must have access to the relevant information regarding the safe management of medicines to people.

We noted PRN protocols lacked information for staff to follow. For example, a person was prescribed a medicine to be administered when they became anxious. The guidance was not clear on what action staff needed to take if the medicine did not work or when to seek further advice.

Prior to our assessment, we received information from the local authority, relating to concerns regarding the provider’s medicines policy. The policy said that only nurses could administer people’s medicines. The policy did not state that care staff were able to administer people’s medicines when nurses were not on shift as confirmed by the management team. When we reviewed the medicine policy it still held this information that only nurses could administer medicines.

As nurses only worked from 8am-8pm, this meant that staff would be required to administer medicines in an emergency. The provider’s policy did not support this practice and there was a risk that people would not receive their medicines in a timely way.

Fridge temperatures were recorded. However, staff were not able to accurately demonstrate how they measured the minimum and maximum temperature and reset the fridge. We also found records did not always contain personalised risk assessments for monitoring high-risk medicines that some people were prescribed such as risk associated with increased bleeding. There was no information on how to monitor the side effects of these medicines.This meant that people may be placed at risk of harm due to lack of guidance on risks associated with high risk medicines.

Following our inspection, the provider has subsequently submitted evidence demonstrating that the concerns have been addressed, helping to reduce the potential risks identified during our visit.