What the CQC found at Glenfield

Staff understood people's preferences and communication needs, although some of this information was not recorded accurately or kept up to date.

“Staff told the inspectors that they enjoyed working at the service and felt supported by their peers and the management team.” from the report

The care plans inspected included personal details, photographs and guidance intended to help staff understand people's routines and preferences.

“All of the care plans we reviewed were personalised. They included photographs and details of things people liked, and things that were important to them.” from the report

People were supported to follow some interests and spend time in the community when staff were available.

“One person had an interest in planes, and so visited the airport frequently. Another enjoyed baking, so was supported to make cakes in the communal kitchen.” from the report

Medicine records contained contradictory information and there was no clear audit trail for a changed dose. The home also had unsafe storage, an out-of-date medicine and staff giving some medicines without the required competency checks.

“There was a significant risk this person was receiving the incorrect dosage of their medicine putting them at serious risk of harm.” from the report

Staff did not always follow positive behaviour support plans. Some people who needed continuous supervision were left alone, increasing the risk of harm.

“People who required continuous supervision to reduce these risks did not always receive this.” from the report

Inspectors found mould, dust, dirt, stains and spillages. A deep clean improved some areas but did not resolve all the problems, and staff did not always use protective equipment correctly.

“One person's bedroom had a stained en-suite with black mould present.” from the report

Not all staff had training in areas including learning disability, autism, epilepsy and diabetes. Some staff had no recorded supervision or competency checks.

“Not all staff had received training in key areas including; supporting people with a learning disability, autism, epilepsy and diabetes.” from the report

Restrictive practices were used without updated mental capacity assessments or best-interest decisions. A blanket restriction was applied because of one person's dietary needs without considering its effect on others.

“Records demonstrated restrictive practices were used without having an updated mental capacity assessment or best interest decision in place.” from the report

The home's audits did not identify serious problems, including medicine and risk concerns. Incident records did not show effective learning, and records were duplicated, inconsistent or out of date.

“Quality assurance systems and processes failed to effectively assess, monitor and improve the quality and safety of the service.” from the report