Glencairn Residential Home

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We reviewed 5 Quality Statements in this key question. We found significant shortfalls in the governance and oversight of the service, there had been a lack of direction and leadership, records were not accurate and contemporaneous and learning was not taken from any incidents. The shortfalls meant there were 2 breaches of Regulations We have issued the provider with a warning notice covering these.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We saw no records of recent staff supervision in staff records, and staff told us they had not recently met with senior staff. One staff member told us they had never had supervision and had worked at the service throughout the COVID-19 pandemic.

There had not been regular staff meetings, however the acting manager had arranged a staff meeting on the second day of our inspection and intended to hold them regularly. When we inspected focus was on improving the service due to records being wrongly disposed of, and the probability the service lacked direction prior to this happening because of poor staffing. Staff were committed to improving the service provided by Glencairn. They acknowledged there were shortfalls in service provision and had faith the acting manager would support them to work together and improve.

We spoke with the provider, and they advised us that while the registered manager had been able to complete training there had not been any specific leadership development, for example, extended learning, attendance of relevant conferences or membership of registered manager groups. The acting manager had recently commenced in post and was focusing on making the most urgent updates to ensure the safety of people using the service. They had begun to evaluate the scale of what was needed to improve the service and ensure it complied fully with Regulations. The acting manager was keen to develop staff from within the service to take on more senior roles by supporting them with additional training and guidance. Staff told us the acting manager was very helpful and had supported them well. Two longer term staff members told us there had not been many opportunities for development under the registered manager, but they had already been able to look at qualification training under the acting manager which they were pleased about. One staff member felt strongly there needed to be more structure in the service and this had been lacking. They felt so strongly about this they told us they would leave should the service revert to how it had been run under the previous management team. Staff also told us they felt unsettled as the service was undergoing significant changes and there was no permanent arrangement for the management team when we inspected.

The leadership team were in the early stages of developing their relationships with people and the staff team which had impacted on both due to the significant changes in the management and wider staff team. Prior to the current acting manager there were challenges with the management teams in post and a lack of leadership. Since the acting manager commenced in post they had started to tackle challenges gradually and making plans to improve the service. The acting manager was taking time to get to know their team and assess their abilities. They had begun to identify staff to train to become future leaders and to take on more responsibility in the service. We were not completely assured of the stability of the service in the future as there was still uncertainty both in the sustainability of current management arrangements and the future arrangements.

The provider had a whistleblowing policy available to all staff members. There were no records of whistleblowing or subsequent investigations. Staff told us they would not have approached the registered manager with concerns. They had raised a concern successfully with the owner resulting in the addition of a senior staff member to a shift, however did not believe their concerns would have been heard by the substantive management team. There was confidence from staff that the current acting manager would listen to any concerns they had. Staff believed if they raised concerns they would be dealt with by the acting manager or provider.

Staff had mostly been trained in equality and diversity, however it appeared from a recent audit that this learning had not been applied to care planning. At the time of our inspection, staff were being supported to participate in 1-1 meetings with the acting manager which could identify areas of support needed.

Staff rotas reflected individual working patterns, for example staff working 2 shifts per week on regular days to accommodate family responsibilities. There was a policy covering equality, diversity and inclusion. There was no evidence of equality and equity being referred to in team meetings which would promote the theme and keep it at the forefront of staff practice.

Staff had not been involved in any auditing of the service. This had been the sole responsibility of the management team.

There was insufficient oversight of the service. The acting manager was still reviewing all aspects of the service when we inspected. The acting manager had addressed the most pressing safety concerns and were auditing all areas before applying a RAG rating to ensure concerns were dealt with according to importance. Prior to the interim manager completing some brief audits in January 2023 we could only find medicines audits, the content of which we were unable to corroborate due to them stating that medicines had been safely disposed of. These medicines were subsequently found in the garage of the service and had not been returned to the pharmacy as stated. All other audits, though seen by a care consultant prior to our inspection, were not available to us and the provider was not able to find them. The acting manager was developing new systems however these were not complete or embedded into practice when we inspected.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff were not able to feedback on this area due to a lack of engagement with learning under the previous management structure.

There was no evidence the service had learned or innovated prior to the acting manager commencing at the service. There was also no evidence of any opportunities for staff members to contribute views and feedback about events prior to the acting managers arrival. The acting manager had demonstrated a drive towards improvements however at the time of inspection, due to the lack of a long term management arrangement we could not be assured this would be sustained. The acting manager had reviewed most aspects of the service and had already begun to implement changes to improve service provision. Meetings had been held with staff, people and relatives and effectively an audit of all aspects of the service was informing the provider of the necessary actions to achieve compliance with Regulations. The nominated individual is responsible for supervising the management of the service on behalf of the provider. When we inspected, this role was held by a care consultant. We spoke with a director of the service and they told us they were keen to drive improvements. However there is evidence to show that improvements identified by the nominated individual prior to our inspection had not been made, and advice from them not always taken. Since this assessment the nominated individual has changed.