CQC report explained · a nursing home
What the CQC found at Gledhow
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, safe medicines management, detailed risk assessments and appropriate infection prevention measures.
- Effective?
- Requires improvement
- This question was not looked at during this inspection. Its previous rating was carried forward into the overall rating.
- Caring?
- Good
- This question was not looked at during this inspection. Its previous rating was carried forward into the overall rating.
- Responsive?
- Good
- This question was not looked at during this inspection. Its previous rating was carried forward into the overall rating.
- Well-led?
- Good
- Inspectors found better audits, clearer care plans, accurate mental capacity assessments and stronger oversight from management.
What inspectors found, July 2021
Rated Good; inspectors found safe care and stronger management after earlier concerns.
Inspectors visited on 17 June and 30 June 2021. They spoke with four people, one relative, five staff and managers. They also checked care records, medicines records, staff recruitment files and quality checks.
The home was rated Good for Safe and Well-led. Inspectors found enough staff, safe medicines management, suitable risk assessments and effective infection control measures. People said they felt safe and staff responded when needed.
The overall rating improved from Requires improvement at the previous inspection. Earlier concerns about governance and mental capacity records had been addressed. This inspection did not assess Effective, Caring or Responsive, so those previous ratings were carried forward.
Safe medicines
Medicines were ordered, stored and given safely. Records showed that people received their medicines as prescribed, with regular checks for errors.
“Medicines were managed safely. Staff administered, stored and ordered medicines in line with best practice.” from the report
Enough staff
Inspectors found enough staff to meet people's needs. Recruitment checks were in place, although agency staff were sometimes used to cover holidays.
“There were enough staff employed to ensure people's needs were being met on a daily basis.” from the report
Improved management
The home had improved its audits, care plans and mental capacity records since the previous inspection. Senior management visits provided more oversight.
“Regular audits were being carried out with actions taken to ensure good practice and regular visits from senior management meant there was sufficient oversight.” from the report
Infection control
Inspectors were assured about the home's arrangements for visitors, testing, protective equipment, cleaning, social distancing and managing outbreaks.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Inspectors raised no specific concerns in this report.
- 01How often are agency staff used, and how do you make sure they know each person's risks and needs?
- 02What checks are now carried out on care plans and mental capacity assessments?
- 03How do monthly medicines audits identify and prevent errors?
- 04What were the previous ratings for Effective, Caring and Responsive, and when will these areas be reviewed again?
- 05How do you check that infection control arrangements remain effective during an outbreak?
This inspection looked at Safe and Well-led, including infection prevention and control; the ratings for Effective, Caring and Responsive were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 28 July 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.
What inspectors found, April 2020
Rated Requires Improvement; inspectors found safe, kind and responsive care, but weaknesses remained in consent records and management checks.
This was a planned, unannounced inspection on 13 and 19 February 2020. Inspectors spoke with people living in the home, relatives and staff. They reviewed care and medicine records, staff files and management checks.
People told inspectors they felt safe and were treated kindly and respectfully. Medicines were managed safely, staffing was generally enough, and people received personalised care, activities and support with food, health and end of life wishes.
The home did not always follow the law when making decisions for people who could not make certain decisions themselves. Some mental capacity assessments and best interest decisions were missing or not properly discussed. Records were also inaccurate, hard to follow or stored inconsistently.
The overall rating was Requires Improvement. Safe, Caring and Responsive were rated Good. Effective and Well-led were rated Requires Improvement. The home had remained Requires Improvement since the previous inspection, and the report says it had been rated this way for the last two consecutive inspections.
Safe medicines
Medicines were administered, stored and ordered safely. Time-critical medicines were given at the prescribed times and audits were being completed.
“Medicines were administered, stored and ordered in line with best practice.” from the report
Kind and respectful care
People described staff as kind and caring. Inspectors found that staff respected privacy, dignity and independence.
“People were treated with dignity and respect.” from the report
Personalised support
Care plans recorded people's preferences, beliefs and routines. People and relatives were involved in six-monthly care reviews.
“Care plans included information about people preferences for care including their likes and dislikes.” from the report
Activities and relationships
The home offered varied activities and helped people follow personal interests. Staff also supported people's cultural and spiritual needs.
“There was a variety of activities within the home and people told us these were enjoyable.” from the report
Inaccurate care records
seriousSome care plans were not detailed or up to date. Inspectors found missing information about mental health and nutrition, and conflicting repositioning instructions.
“Care plans were not always detailed and accurate.” from the report
Poor record organisation
needs fixingInformation was not recorded consistently or kept in the same place. This made it difficult for staff to find the most current information.
“There was no consistent approach to recording information.” from the report
Night staffing
needs fixingSome night shifts were not fully staffed. On a few occasions there were four staff rather than the required five, although inspectors judged overall staffing sufficient.
“On a few occasions there were only four staff working at night rather than the required five.” from the report
Controlled drug competency
needs fixingThree staff had witnessed controlled drug signatures without having completed a competency assessment or training. Managers said they would arrange two nurses at night until carers were competent.
“We found three staff who had witness signed for controlled drugs but had not received a competency assessment or training.” from the report
- 01How do you now make and record mental capacity assessments when someone is restricted, such as with bed rails?
- 02How are best interest decisions discussed with relatives and other relevant people?
- 03How do you check that care plans are accurate and up to date, including mental health, nutrition and skin care information?
- 04How do you ensure repositioning instructions and charts agree, and record when someone refuses to be repositioned?
- 05How do you ensure every night shift has the staffing level needed for the people living here?
This was a planned, unannounced inspection covering all five key questions, with the full service and its care and records examined. This explanation was written from the published report of 8 April 2020 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 Gledhow
5 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- July 2021Goodcurrent ratingup from Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- April 2020Requires improvementstayed Requires improvementSafe: GoodWell-led: Requires improvement
- February 2019Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- November 2011
Registered with the Care Quality Commission on 10 November 2011.
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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At least 100 live-in carers within about an hour of Leeds
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,250 a week. 89 can care for a couple. 11 years' experience on average.
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