A new inspection at a crisis-hit Glenrothes care service has revealed a series of further “critical” failures – including “falsified” medication records.
Inspectors made their latest in a series of visits to Glamis House – which offers supported living service for people with disabilities and health conditions – in September.
Findings included accounts of residents wanting to cry because of their treatment, and psychoactive drugs being used on people without medical advice.
It has sparked a further demand for improvements at the site – or it could face closure.
Problems were first discovered at the Leonard Cheshire-run facility in March, with a follow-up visit by the Care Inspectorate in May.
A lack of progress in solving the earlier issues resulted in the facility’s leadership team being suspended.
The Courier also revealed how one resident who received nutrients through a line in her stomach had been left for 18 hours without care.
What does the latest Glamis House report say?
Details from the Care Inspectorate’s latest visit to Glamis House on September 6 have only now been revealed.
It found “critical weaknesses in aspects of the service which significantly affected the care that people received”.
All areas of the service were rated “unsatisfactory”, the lowest possible rank, including support for residents’ wellbeing, leadership and staffing, with urgent improvements now called for.
Inspectors say service users’ physical and mental health were put at risk.
The report says residents were “not afforded the right to make choices and decisions about their lives”.
It added: “People were not supported to go out socially or even to do their shopping.
No social contact for two years
“Some people had not seen friends since the beginning of the pandemic.
“People we spoke to were distressed and told us they were sad. We observed poor practice and values from staff.
“People’s privacy and dignity was not respected and people were not even acknowledged in their own homes. People told us this made them want to cry.”
Medication records ‘falsified’
Inspectors found regular medication errors over an extended period of time, prompting “significant” concerns about medicines management.
The report said: “We identified evidence that medication records were falsified to indicate missed medication had been given.”
It also said no medical advice was sought when people did not receive medication as prescribed.
Inspectors found no action had been taken to address errors, leaving residents at “significant risk of harm”.
Powerful drugs used without medical advice
Other medication issues identified included staff members’ use of powerful “psychoactive” drugs, which can be used as a form of chemical restraint.
The report said: “Psychoactive medication should be administered as a ‘last resort’ when all other strategies and approaches have been attempted.
“However, people did not have appropriate care plans in place. We noted one person was given ‘as required’ psychoactive medication on a daily basis for an extended period of time.
“No medical advice was sought to support the person.”
People ‘fear reprisal’ for complaining
Meanwhile, inspectors found those living at Glamis House had asked them not to tell managers they had complained, saying they feared reprisals.
The report added: “People said they did not have confidence their service would improve. People were distressed and despondent.”
What happens next at Glamis House?
The Care Inspectorate has escalated its action against Glamis House, using regulatory powers to issue an improvement notice against the service.
It means Leonard Cheshire must make a number of required improvements by October 31.
This includes ensuring service users are given safe support in relation to medication, with a number of requirements in terms of staff training.
If those are not met, the service could be shut down – but the regulator says this is “rare” and a “last resort”.
What does operator Leonard Cheshire say?
Leonard Cheshire previously said that the new management team had been appointed to address “longstanding challenges”.
The firm insists a number of positive changes have been made since the latest inspection which have been “acknowledged by families” with loved ones at Glamis House.
A spokesman said: “We’ve been working closely with the Care Inspectorate and the Health and Social Care Partnership (HSCP) so that all necessary improvements are delivered as soon as possible.
“We have been delivering targeted training, including around medication. The Care Inspectorate and HSCP have provided sessions on care values and safeguarding.
A new management team is making good progress
Leonard Cheshire
“A huge amount of additional resource and senior oversight is being provided on site at the service.
“A new management team is making good progress. All personal and medication plans have been reviewed and updated where necessary.
“New support staff have been recruited to address longstanding vacancies. We are committed to driving forward more improvements at Glamis House, so that everyone living there is happy and supported to the highest standards.”
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