Background to this inspection
Updated
14 October 2020
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.
Inspection team
The inspection team consisted of two inspectors.
Service and service type
The Glynn residential home is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
The service had a manager registered with the Care Quality Commission. This means they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
Notice of inspection
We telephoned the registered manager on the morning of the inspection to announce the inspection. This was due to the Covid-19 pandemic to ensure we had prior information to promote safety.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority commissioning and safeguarding teams. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made judgements in this report. We used all of this information to plan our inspection.
During the inspection
We spoke with two people who used the service. We looked at some people's rooms and equipment used for moving and handling. We spoke with the registered manager and reviewed a range of care records.
After the inspection
We requested further information from the registered manager, including care plans and quality assurance documents, which we reviewed as part of the inspection process. We held a telephone meeting with the registered manager to clarify some information in the documentation sent and validate evidence found. We spoke with eight staff by telephone. We had a telephone discussion with the district nurse, the infection control team and the local authority safeguarding adults team.
Updated
14 October 2020
About the service
The Glynn is a residential care home providing personal care to 28 people aged 65 and over at the time of the inspection. The service can support up to 38 people.
The Glynn accommodates 38 people over two floors, with communal areas on the ground floor.
People’s experience of using this service and what we found
People were at risk of avoidable harm because risks had not been adequately assessed, monitored or mitigated. Care records did not contain sufficient information for staff to know how to care for people safely or understand their individual risks. Staff had not received adequate safety related training. Equipment was not assessed for individual use, or robustly checked to ensure people could use this safely. Systems and processes did not ensure the safe management of medicines or suitably skilled and trained staff.
Quality assurance processes were weak and no improvement had been made to address the breach at the last inspection or recognise further breaches in regulations we identified at this inspection. Audits were incomplete and ineffective and did not identify issues highlighted through the inspection process. Records of people's care were not accurate or detailed.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was requires improvement (published 13 July 2019) and there was a breach of regulation 17, Good governance. The provider sent us an action plan to show what they would do to improve. At this inspection, enough improvement had not been made/ sustained and the provider was still in breach of regulation 17, with further breaches identified in regulation 12, Safe care and treatment, regulation 13, Safeguarding service users from abuse and improper treatment and regulation 18, Staffing. There was a breach in part of the registration regulations in relation to the requirement to notify CQC of significant events.
Why we inspected
This was a planned inspection based on the previous rating. The inspection was prompted in part due to whistleblowing concerns received about poor management of risks. The inspection was also prompted in part by notification of a specific incident following which a person using the service died following a serious injury. This is subject to a separate investigation by CQC. The information CQC received about the incident indicated concerns about the management of individual risks to people's health and safety. A decision was made for us to inspect and examine those risks. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.
We have found evidence that the provider needs to make improvements. Please see the Safe and Well-Led sections of this full report.
You can see what action we have asked the provider to take at the end of this full report.
The provider took some immediate actions following the inspection, such as arranging for lifting to be serviced and referring to the GP for people's specific health needs.
We reviewed the information we held about the service. No significant areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.
The overall rating for the service has changed from requires improvement to inadequate. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Glynn on our website at www.cqc.org.uk.
Enforcement.
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.
We have identified breaches in relation to people's safe care and treatment, safeguarding people from abuse, staff skills and staff training, and management of the service.
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
Since the last inspection we recognised that the provider had failed to notify CQC of safeguarding concerns. This was a breach of regulation. Full information about CQC’s regulatory response to this is added to reports after any representations and appeals have been concluded.
Follow up
We met with the provider following the inspection, to seek immediate assurances about the concerns found. We liaised with the local authority to ensure their support for the provider to improve.
The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.
If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.
For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.