6 July 2022
During an inspection looking at part of 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.