CQC report explained · a residential care home
What the CQC found at Glasshouse College
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Risks were identified and care plans told staff how to support people safely. Inspectors found sufficient staff, safer medicines systems and appropriate safeguarding processes, although fire risk assessments were still being completed.
- Effective?
- Good
- People received relevant support, training and healthcare. The home had improved its assessment process, house moves and coordination between education, residential care and outside professionals.
- Caring?
- Good
- Staff treated people with kindness, dignity and respect. People and their families were involved in care decisions, and staff supported people to develop skills and independence.
- Responsive?
- Good
- Care records included people's preferences, history and important relationships. People were supported with communication, activities, relationships and everyday living skills in ways suited to their needs.
- Well-led?
- Good
- The registered manager had improved quality monitoring and created a service improvement plan. Inspectors found a more positive culture, although some daily records and communication with professionals could be improved.
What inspectors found, April 2022
Glasshouse College is rated Good; inspectors found major improvements in safety, care and management, and the home was taken out of special measures.
Inspectors visited eight residential houses and the college campus over four days. They met people, observed care, spoke with staff and relatives, reviewed care and staff records, and contacted health and social care professionals.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found people were treated kindly, supported to become more independent, helped to access the community and given their medicines safely.
This was a clear improvement from the previous Inadequate rating, published in September 2021. The earlier breaches relating to safe care and treatment and quality monitoring had been met, so the home was no longer in special measures.
Safer care
Risks were assessed and staff knew how to respond to people's needs and early signs of distress. Medicines were given safely and checked.
“People received their medicines on time and in a safe way.” from the report
Kind and respectful staff
Inspectors saw people being treated with kindness and respect. Staff knew people's needs, preferences and goals.
“People were supported by caring and kind staff.” from the report
Greater independence
People were supported to learn everyday skills, use community facilities and try new activities.
“People had the opportunity to try new experiences, develop new skills and gain independence.” from the report
Improved leadership
The home had stronger oversight, regular audits and a service improvement plan with actions allocated to staff.
“The registered manager had oversight of the system, and it was effective.” from the report
Fire risk assessments still underway
needs fixingAn independent assessor was completing workplace fire risk assessments during the inspection. The outcome and any required actions were not yet available to inspectors.
“Workplace fire risk assessments were being completed by an independent assessor at the time of our inspection.” from the report
Daily records
needs fixingInspectors said some daily records did not contain enough detail to show the care and support people had received.
“some daily records could be more detailed to evidence the care and support provided to people” from the report
Healthy eating
minorOne relative felt there could be more emphasis on healthy eating. The registered manager said work was continuing in this area.
“One relative told us there could be more emphasis on healthy eating.” from the report
- 01What was the outcome of the independent fire risk assessment, and have all resulting actions been completed?
- 02How are you making sure daily records contain enough detail about the care and support provided?
- 03How many staffing posts are still vacant, and how often are regular agency staff used?
- 04What changes have been made to improve healthy eating and access to healthier food?
- 05How do you now make sure communication with commissioners and health professionals is consistent?
This inspection was carried out to check improvements after the previous Inadequate rating and considered all five key questions, including the residential premises and personal care, but not the educational provision regulated by Ofsted or the premises used by shared lives carers. This explanation was written from the published report of 20 April 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, October 2021
Rated Inadequate and placed in special measures; inspectors found serious safety and management failures, despite kind staff and some good support.
Inspectors visited on 21, 22 and 24 June 2021. They spoke with people, relatives, staff and health professionals. They visited five of the 13 houses and checked care plans, risk assessments, medicines records, staff files and management records.
The home was not safe. Risk assessments did not always give staff clear instructions. Known risks included choking, self-harm, unsafe bedroom items and health conditions that were not fully recorded. Some houses were poorly maintained, and some kitchens and bathrooms could not be cleaned effectively.
Inspectors also found weaknesses in care planning, health action plans and the way the home checked its own quality and safety. Staff were described as kind and supportive, and people received their medicines when needed. However, the overall rating was Inadequate because the safety and leadership failures put people at risk of avoidable harm.
This was the first rating for this newly registered service. The inspection was prompted partly by a death following a specific incident, but the report says the inspection did not examine the circumstances of that incident because it is subject to a criminal investigation.
Kind staff
People told inspectors that staff were kind and friendly. Inspectors also saw kind and caring interactions.
“All of the people we spoke with told us staff were kind and friendly.” from the report
Medicines
The medicines records checked were accurate. Medicines were stored safely, and staff competence was assessed.
“Records and the number of medicines remaining for the three people whose records we checked were correct.” from the report
Consent and least restriction
Staff understood the Mental Capacity Act and asked people for consent before providing support.
“People we spoke with told us staff asked for their consent before they gave support.” from the report
Activities and community life
People took part in college activities, hobbies and outings, including time with family and friends.
“Records confirmed people were involved in a range of external activities including, eating out and going to the cinema and seeing family and friends.” from the report
Safeguarding arrangements
The home had a safeguarding team that reviewed incidents and considered referrals to the local authority.
“There was a dedicated safeguarding team and they met daily at the college.” from the report
Risks were not managed
seriousImportant risks were not always fully assessed or clearly explained to staff. Inspectors found concerns involving choking, self-harm, bedroom hazards, a window and health needs.
“Risk's to people's health and welfare were not mitigated.” from the report
Weak quality checks
seriousThe home’s governance systems did not identify all the problems inspectors found, or ensure prompt action when problems were known.
“Systems to assess, monitor and improve the quality and safety of the service were not effective.” from the report
Incomplete health information
needs fixingHealth action plans did not always record conditions, warning signs or the support staff should provide. This could make consistent care more difficult.
“Health action plan documents were in place. However, these were incomplete documents with missing information about health conditions, signs and symptoms for staff to be aware of and the monitoring of health conditions.” from the report
Poor condition of some houses
needs fixingSome houses were comfortable and homely, but others had worn or damaged areas and were not always fit for purpose. The provider said one house would be decommissioned.
“some required significant improvement to ensure they were fit for purpose.” from the report
Unclear evacuation arrangements
needs fixingThe arrangements for people to evacuate safely from two houses needed clarification. The provider later gave assurance that identified fire risks had been dealt with.
“The arrangements in place for people evacuating safely in two house's that we visited required clarification and this assurance was provided.” from the report
- 01What changes have been made to the risk assessments for choking, self-harm, bedroom hazards and health conditions?
- 02Which houses have been repaired or decommissioned, and how do you check that each remaining house is fit for purpose?
- 03How are incomplete health action plans now checked, and how are staff told about warning signs and required support?
- 04What evidence can you show that fire evacuation arrangements are now clear and safe in every house?
- 05How do managers now check that known risks are acted on promptly and that care records are complete?
The inspection was initially planned to focus on Safe and Well-led, but concerns led inspectors to assess all five key questions; CQC regulated the premises and care in the residential houses, but not the premises used for shared lives placements or the educational provision. This explanation was written from the published report of 13 October 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Glasshouse College
5 rated inspections over 7 years: the service has held its Good rating throughout.
- April 2022Goodcurrent ratingup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2021Inadequatedown from GoodSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- January 2020Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2020
Registered with the Care Quality Commission on 14 August 2020.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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