CQC report explained · a residential care home
What the CQC found at Glenfields Care Home Limited
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People's medicines were administered safely and staff understood people's risks. However, guidance for medicines given when needed was lacking, and some risk, fire and recruitment records needed improvement.
- Effective?
- Good
- This question was not inspected during this focused inspection. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This question was not inspected during this focused inspection. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This question was not inspected during this focused inspection. Its previous rating was used when calculating the overall rating.
- Well-led?
- Requires improvement
- The home had a positive culture and the manager had started making changes. However, quality assurance systems had not identified several shortfalls, and the provider remained in breach of Regulation 17.
What inspectors found, January 2023
Glenfields Care Home Limited is rated Requires Improvement; inspectors found caring staff but weaknesses in medicines guidance, records and quality checks.
This was an unannounced focused inspection on 23 November and 5 December 2022. Inspectors looked only at Safe and Well-led. They spoke with people, relatives and staff, observed care, and checked care records, medicines records, recruitment files, rotas, training and audits.
People were generally kept safe and staff were trained, knowledgeable and caring. Medicines were given safely, but staff did not always have enough written guidance for medicines given when needed. Risk assessments, fire drill records and recruitment records also needed improvement.
The home had a positive culture and people and relatives were mostly happy with the care. However, the quality checking systems had not found the problems inspectors identified. The home remained in breach of Regulation 17 on good governance and was rated Requires Improvement overall, as it had been at the previous inspection.
Medicines administered safely
Trained and competent staff gave people's medicines safely. The manager investigated a stock discrepancy promptly.
“People's medicines were administered safely by trained and competent staff.” from the report
Skilled staff
Staff received induction and regular training. People and relatives were positive about staff's skills and manner.
“People and their relatives told us staff had the right skills to support them and staff were positive about the training provided.” from the report
Kind and respectful care
Inspectors found a positive culture. People were treated with dignity and care plans included personal preferences and needs.
“There was a positive culture at the service which promoted people's rights.” from the report
Infection control
Inspectors were assured that the home had arrangements to prevent and manage infections. Some visitor PPE processes were changed during the inspection to match guidance.
“We were assured that the provider was responding effectively to risks and signs of infection.” from the report
Weak quality checks
seriousAudits did not identify problems with medicines and records relating to risks, fire safety and recruitment. The provider remained in breach of Regulation 17.
“The provider had failed to ensure governance systems were robust and effective to identify shortfalls in the service.” from the report
Medicines guidance
needs fixingStaff knew when people needed medicines given when required, but written protocols did not explain clearly when these medicines should be given.
“However, there was a lack of protocols to guide staff when they should be administered.” from the report
Risk and fire records
needs fixingMost risk assessments were present but were not always reviewed regularly. One catheter-related assessment was missing, and fire drill records lacked enough detail.
“Most risk assessments were in place but had not always been regularly reviewed, though this had improved.” from the report
Mixed views on staffing
minorInspectors found enough staff to keep people safe and meet their needs, but feedback about staffing levels was mixed. The provider was trying to recruit more permanent staff.
“We received mixed feedback about staffing levels at the service, but people and their relatives were consistently positive about the staff who supported them.” from the report
- 01What written protocols are now in place for medicines given when needed?
- 02How are risk assessments reviewed regularly, including assessments for people with catheters?
- 03What extra detail is now recorded after fire drills, including response times and actions?
- 04How have quality audits been changed so they identify medicines, risk, fire and recruitment record problems?
- 05What progress has been made with the manager's registration and the action plan requested by CQC?
This was a focused inspection of Safe and Well-led only; the other question ratings carried over from the previous inspection and were used to calculate the overall rating. This explanation was written from the published report of 12 January 2023 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, July 2021
Glenfields Care Home Limited is rated Requires Improvement; care was safe and responsive, but management checks and records were not reliable.
This was a focused inspection over two days. Inspectors spoke with people living at the home, relatives and staff. They reviewed care, medicines, recruitment, training and management records, and checked infection control arrangements.
Inspectors found that people were safe, received their medicines as prescribed and were supported by caring staff. The home supported visits, activities and contact with relatives. Complaints had been responded to and lessons had been considered.
The main weakness was management oversight. Quality checks were not carried out properly and did not identify problems with care records, risk reviews, topical medicine records and COVID-19 testing. The overall rating fell from Good to Requires Improvement, while Safe and Responsive remained Good and Well-led fell to Requires Improvement.
Safe medicines and environment
People received their medicines as prescribed. Medicines were stored securely, clinical rooms were clean and staff checks were carried out.
“Medicines were stored securely and disposed of correctly. Clinical rooms were clean and organised.” from the report
Caring staff
People were described as happy and supported well. Staff spent time talking with people and learned about their lives and preferences.
“Staff spent time with people having meaningful conversations, whilst gaining information about people's life histories, experiences and things of importance.” from the report
Activities and relationships
People were supported to stay in touch with relatives and friends and to take part in activities that interested them.
“People enjoyed a variety of activities and staff were proactive in finding out what interested people, what was important to them and what would encourage them to take part in activities.” from the report
Complaints were acted on
Complaints about visiting had been acknowledged and answered. The home considered lessons from them and took action.
“These complaints had been acknowledged and responded to. Lessons learnt had been considered and acted upon.” from the report
Weak management checks
seriousThe provider's audit schedule was not followed. Quality checks failed to identify several problems found by inspectors, including gaps in care records and COVID-19 testing.
“Quality monitoring tools used did not highlight areas that we found on inspection.” from the report
Risk reviews were not recorded
needs fixingRisk records were present, but they did not show that reviews had taken place regularly. The provider was asked to improve staff training and recording.
“Records of recorded risks did not show reviews had taken place on a regular basis.” from the report
Care records were incomplete
needs fixingThe new electronic care planning system did not always show the personalised support people received. Records for topical medicines were also initially missing, although the provider added the required documentation during the inspection.
“Records did not always reflect the personalised support people received.” from the report
COVID-19 testing gap
needs fixingPeople had not been tested in line with the 28-day government guidance during May 2021. The provider arranged tests after inspectors raised this.
“People had not been tested in line with the 28-day Government guidance within May 2021.” from the report
- 01How are you now checking that people's risks are reviewed regularly and that those reviews are recorded?
- 02What quality checks are now in place to identify missing or incomplete care records?
- 03How do you check that topical medicines are recorded correctly?
- 04What process ensures people receive COVID-19 tests in line with current guidance?
- 05What action has been taken since the Regulation 17 breach, and when was the last quality review completed?
This was a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected, and their ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 9 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.
Every inspection of Glenfields Care Home Limited
4 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- January 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Glenfields Care Home Limited →
- July 2021Requires improvementSafe: GoodWell-led: Requires improvement
Read what inspectors found at Glenfields Care Home Limited →
- January 2021Inspected but not ratedSafe: Inspected but not rated
- January 2019Goodstayed GoodSafe: GoodResponsive: GoodWell-led: Good
- July 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 11 January 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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