Glendon House

At this inspection, shortfalls were identified within the governance system which meant there was a lack of monitoring and oversight of how the service was performing. The systems in place did not identify some of the shortfalls we identified as part of this inspection, including environmental issues. Audits were not consistently being completed, which meant risks were not being identified or addressed in a timely way. Those that were completed failed to identify issues such as gaps in monitoring records. There was poor identification and management of themes, trends and lessons learnt meaning opportunities for improvement were missed. The system for recording staff training and competencies was incomplete and did not give oversight of this area. Meetings were not all being recorded. Overall, this meant we were not assured the Nominated Individual and registered manager had complete understanding of how well the service was being run and where improvements were needed. The management team were responsive to concerns raised as part of this inspection and made changes to give better oversight of the audit schedule, improve system for capturing lessons learnt and recording of training and competencies.

However, the service demonstrated a caring culture, with positive relationships between staff, people and relatives. People were treated with kindness, dignity and respect and staff knew them well, supporting their preferences and independence. People were offered choice in their care and were encouraged and supported to maintain relations with their family and friends, where this was their wish.

There were sufficient staff to meet people’s needs and people were protected and kept safe. Staff understood and managed risks to people’s wellbeing. The environment was clean and well-maintained. The provider supported and valued the staff which helped promote wellbeing and positive morale.

The service was integrated into the local community with visits from local schools, a beautician, hairdresser and pastors from the local church. People went to classes in the community and a fete was held within the grounds. The activities team led a variety of events for people from exercise classes and music, to visits from animals, entertainers and themed events including Easter, VE day and ‘staycation’ exploring 6 different countries. There were trips out to the beach and local attractions.

People were involved in decisions about their care and knew how to give feedback or raise concerns and were confident it was taken seriously and acted upon.

The management team and staff had a shared vision and culture based on listening, learning and trust. Managers were visible, knowledgeable and supportive, helping staff develop. Staff felt supported to give feedback and were treated equally, free from bullying and harassment.

We have found the provider was in breach of good governance and have asked the provider for an action plan in response to the concerns found at this inspection.