Gloriavd Health Care Ltd

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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

This key question has been rated requires improvement. We reviewed 3 quality statements for this key question. We identified 1 continued breach of the legal regulations. There were quality assurance processes and procedures in place but during this inspection we found these had not always been effective in identifying and addressing the issues with medication records and recording of decisions for people who lacked capacity to make decisions about their care. The provider ensured actions were taken and lessons learnt following incidents. Staff told us they felt supported by the management team and people said any issues raised were acted upon.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The registered manager explained the actions they had taken to support staff, this included additional support provided during the initial months to staff who came from overseas. During our inspection, staff reported feeling well supported by the management team and felt any concerns raised would be acted upon. Their comments included, "I can tell the management about any concerns, and they will deal with this" and "The manager listens to us and responds to any concerns raised."

There were policies and procedures in place to encourage people, relatives and staff to speak up and we found these were being followed. People and relatives told us they were confident in raising any concerns to the manager and were confident these would be acted upon. Comments included, "I would see [name of registered]. [Name of registered manager] Comes in to check on the carers, we get on well with [name of registered manager]. [Name of registered manager] is efficient."

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

In our conversations with the registered manager, they told us how they kept an oversight of the safety and quality of the service through their regular audits and conversations with staff, people and relatives. During this inspection, we found examples of this oversight not being fully effective, for example with the gaps in recording of medication or mental capacity assessment records. The registered manager was responsive during our inspection and took timely action on the issues identified.

There were quality assurance processes and procedures in place but during this inspection we found these had not always been effective in identifying and addressing the issues with medication records and recording of decisions for people who lacked capacity to make decisions about their care. During this inspection we reviewed the provider's quality assurance documentation and found audits and spot checks were happening. In some audits done by the provider, issues with medication records not being accurate had been identified, however, we continued to find issues in this area during our inspection. The provider had not previously identified that mental capacity assessments and best interest decisions were not always being completed. Risks that were identified with one person's moving and handling arrangements had also not been identified in the provider's own audits of care. This show the quality assurances processes in place were not always effective. This was a continued breach in regulation 17 (good governance) because the systems in place were not always operating effectively.

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.

In our conversations with the registered manager, they told us how they ensured learning and improvements and gave have us several examples of how they had changed how they managed the service following incidents.

During this inspection, we reviewed evidence confirming actions were taken and lessons learnt following incidents, some included safeguarding concerns. For example, a new system was put in place to monitor and record the application of transdermal patches following an incident.