Glyn House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This is the first assessment for this service, we assessed all quality statements. At this assessment, the rating for this key question is requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. We observed people being safely supported by staff and most relatives told us people were safe living in the home. Where people experienced incidents of distressed behaviour, these incidents were recorded on incident records. However, not all incidents were reviewed by the management team and some incidents recorded people being restricted from making their own choices and decisions. These restrictions had not been identified or acted upon. Where incidents identified self-injurious behaviours, some of these incidents had not been shared with the appropriate professionals, such as the safeguarding team. This placed people at increased risk of harm. This was a breach of regulation as people were not always safeguarded from abuse and improper treatment. Risks to people from health conditions and activities were assessed appropriately and staff told us how they supported people to manage these risks. People were encouraged to experience new activities, and they were supported to follow their interests. There were enough staff on duty to support people and staff were recruited safely. Medicines were stored and administered safely, however medicine records needed further detail to ensure they recorded clear protocols for staff to follow. The home was clean and well maintained.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Relatives told us incidents and accidents were investigated. However, 1 relative told us lessons learnt from incidents or accidents were not always shared in a timely manner. The registered manager shared their plans to meet more regularly with relatives to enable further discussions around concerns and review people’s care.

Staff told us lessons learnt from incidents and accidents were discussed in team meetings and handovers. However, we discussed actions taken following incidents and accidents with members of the management team. Lessons learnt from incidents involving distressed behaviour and rationale for actions taken by staff were not always clearly recorded or reviewed.

The learning culture did not always promote lessons learnt from incidents and complaints. Minutes of team meetings recorded discussions around incidents and accidents. However, some incidents involving distressed behaviours were not always investigated or recorded on the provider’s electronic system. This meant the provider could not be assured all incidents were reviewed in accordance with their policies and procedures. The registered manager responded to our feedback by carrying out an investigation and introducing new incident recording and reporting processes. The registered manager also referred people who presented with self-injurious behaviours to other relevant professionals to gain additional support and insight. Lessons learnt from complaints were not always actioned in a timely manner. Following lessons learnt from a previous complaint, the provider identified 3 actions for themselves to implement. However, 1 of the actions had not been implemented despite more than 3 weeks passing. The registered manager responded to our feedback by completing the action.

Relatives told us people were safe living in the home and our observations found people appeared comfortable and happy with the staff who supported them.

Staff told us people’s needs were regularly reviewed and systems were in place to support people safely. However, where staff were required to complete daily checks and update people’s progress towards their goals, there were numerous gaps in the recordings.

One visiting professional told us the provider supported a person to develop new skills, which enabled them to become more independent. However, another visiting professional told us, “Whilst some staff are open to new innovations or approaches, the application of these may not be consistent, with some approaches not being tried or only tried once or twice.”

Systems were in place to keep people safe, such as risk assessments and quality assurance checks. However, some systems in place were not always managed safely. For example, some people experienced health conditions, such as epilepsy and required their seizure monitoring equipment tested daily but there were gaps in the records. The registered manager responded to our feedback by introducing new quality monitoring systems to check equipment was tested daily.

Relatives told us people received safe care and treatment. However, one relative told us they were not kept informed of actions taken following safeguarding concerns in a timely manner.

Staff told us they received safeguarding training and were confident to raise concerns. One staff member told us, “We would report any safeguarding concerns to the senior or the registered manager. If nothing was done, we would go to the district manager or the local authority safeguarding team.” The registered manager raised safeguarding concerns with the local authority. However, where incidents involving distressed behaviours occurred, there was not always a clear rationale explaining why these incidents were not reported to the safeguarding team. Following our feedback the registered manager contacted the Local Authority safeguarding team and raised the appropriate referrals.

Our observations showed people were supported safely by the staff team. Where people displayed distressed behaviours the staff team responded calmly and provided assurances.

Safeguarding posters and easy read materials were available on display in the home. However, concerns from incidents involving distressed behaviour were not always reported to the safeguarding team in a timely manner. Incidents involving distressed behaviour were not always investigated and reviewed. Where incidents included restrictions being placed upon people, such as people being restricted from accessing their belongings, there was not always any clear rationale recorded or best interest decisions explaining why the person was restricted. Failure to follow up and report safeguarding concerns and failure to identify and remove restrictive practices constituted to a breach of regulation. The registered manager responded to our feedback by reviewing systems to ensure all future incidents of concern were reported to the safeguarding team and restrictive practices were discussed with the staff team.

People were encouraged to take risks and develop independently. However, where people’s choices were restricted, for example a person not having access to their touchscreen tablet computer during the late evening, there was no clear rationale to support such restrictions.

Staff told us how they actively promoted people’s decisions and choices. However, we discussed incidents where people were restricted from making their own decisions by staff without clear rationale, for example one person was restricted from wearing their choice of jumper due to this being unclean. This is not acceptable practice because people have the right to make their own choices and decisions, even if these choices are deemed as being unwise. The manager responded to our feedback by reviewing restrictive practice with the staff team.

Throughout both site visits, we observed staff encouraging people to make their own choices and respecting their decisions.

Risks to people from health conditions and activities were clearly assessed and recorded. However, some risks to people were not being clearly managed in accordance with health professional advice. One person was referred to a health professional due to risks identified from the person’s behaviour. Following consultation, the health professional produced a series of recommendations. However, records were not available to evidence whether these recommendations had been followed. The registered manager responded to our feedback by introducing new processes to record actions taken to meet professional recommendations.

People lived and were supported in a clean and well-maintained home, although some areas of the home appeared a little tired. The registered manager shared their scheduled renovation plans.

Staff said people were supported in a well-maintained home. Staff told us they told us they took part in regular health and safety checks such as fire evacuation tests.

The home was generally tidy, clean and well maintained. However, during day 1 of the site visits we observed a can of aerosol left out in a communal bathroom and we raised concerns over wardrobes not being attached to walls. This is important to prevent heavy furniture falling onto a person and causing an injury.

Health and safety checks took place to ensure the home was compliant with health and safety regulations. The registered manager was proactive to our observational concerns. On day 2 of the site visits, aerosols were locked away and wardrobes were secured to the walls.

People were supported by an appropriate number of trained staff. Relatives told us people received appropriate support. One relative said, “The staff are brilliant, they are very well trained. There is always plenty of staff. They all know what [my family member] needs and wants.”

Staff told us there were enough staff available to support people safely. One staff member told us, “There are enough staff on duty, we are never short staffed. There are loads of training courses to complete, both e-learning and face-to face.”

We observed staff supporting people on a 1:1 basis in the home and supporting people to access the community. Where people wanted privacy, we observed how staff respected this choice but remained near-by in case people wanted or needed support.

There were enough suitably qualified staff to support people safely. Staff rotas were in place and the management team regularly reviewed staff training. Staff were recruited safely. Recruitment files showed all pre-employment checks had been made to ensure only staff who were suitable to work with people were employed.

Relatives told us staff followed infection prevention control (IPC) practices. One relative said, “Staff always wear their gloves and aprons.”

Staff told us they received infection prevention control training (IPC). One staff member said, “I have received IPC training. It's important we all follow safe IPC practices to prevent any infection or cross contamination.”

The home was clean, and we observed staff cleaning areas of the home. However, face masks were not being stored in accordance with infection prevention control principles. They were left in a communal bathroom with the packet open. This meant airborne infections could land on the face masks and they were exposed to moisture.

The provider carried out infection prevention control audits. However, further action was required to raise awareness with the staff team regarding the correct storage of personal protective equipment (PPE), such as face masks. On the 2nd day of the site visits the masks were stored safely.

One relative told us, “The staff deal with all [my family member’s] medicines I have no concerns, the staff know what they are doing.” However, another relative told us about a medicines error. They explained no harm was caused to the person concerned, although they had not received any feedback or lessons learnt to be assured steps had been taken to prevent similar errors occurring in the future.

Staff told us they received safe handling of medicine training, and their competencies were regularly reviewed. One staff member told us about STOMP, they said, “STOMP is all about not over medicating people with learning disabilities.” STOMP is a national NHS England work programme to stop the inappropriate prescribing of medicines for people with a learning disability, autism or both.

People’s medicines were managed and administered by suitably trained staff. People got their medicines at the right time and medicines were reviewed regularly. Where people needed their medicines when required or where people needed their medicines hidden in food, there were protocols in place. However, some of these protocols missed signatures and required updating to ensure they clearly outlined the steps for staff to follow. Where 1 person required medicines to be administered following an absence of bowel movements, there was confusion over how many days before administering the medicine. The registered manager contacted the pharmacy for clarity and updated the protocols.