The Firs Care Home

Updated 28 October 2023

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 Health and Social Care Act 2008.

Inspection team

This inspection was completed by 1 inspector.

Service and service type

The Firs Care Home a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. The Firs Care Home is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 3 people who lived at the home and 3 people’s relatives. We also spoke with the registered manager, deputy manager, the cook, 5 care assistants, a volunteer, and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We looked at the care records for 3 people and multiple medicines records for people living in the home. We checked the care people received matched the information in their records. We looked at records relating to the management of the service, including audits and recruitment checks carried out within service.

Updated 28 October 2023

About the service

The Firs Care Home is a residential care home providing accommodation and personal care to up to 26 people. The service provides support to older people some who may be living with dementia. At the time of our inspection there were 20 people using the service.

People’s experience of using this service and what we found

Medicines administration was not carried out safely or in line with the provider’s policy. Medicines open dates were not always recorded and protocols for ‘as and when required’ medicines were not always reviewed in a timely manner. Medicine trolleys were not stored securely. Risk assessments were not always sufficient to mitigate identified risks to people.

The provider could not always be assured robust recruitment checks had been carried out. Incidents and accidents were recorded though analysis of these to identify patterns and trends was not in place. Infection control practices were followed, and a new decorating programme had begun to address environmental areas needing a refresh.

The provider and registered manager did not have sufficient oversight of service delivery; audits of the service delivery were not effective or robust. The registered manager and staff worked with other professionals and families.

Staff had not all received sufficient and suitable training. Assessments of people’s needs were not always sufficiently detailed or addressed in their care plans. Staff supported people to eat and drink, though records of this did not reflect the practice of staff. People were asked for their consent when being supported by staff and had access to health care services when needed.

Care plans were not always person-centred. While no-one was receiving end of life care, there were end of life care plans in place. Complaints about the service were recorded and investigated where required.

The staff and registered manager were caring. They considered people’s equality, dignity and respect in every aspect necessary. People’s views were actively sought by the service and these were listened to and actioned.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 03 April 2019).

Why we inspected

The inspection was prompted in part due to concerns received about people’s safety. A decision was made for us to inspect and examine those risks.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvements.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment of people, records not being person-centred and oversight of service delivery at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.